Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 1 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children’s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available; we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 2 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:___________Arizona_________________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name:

Position/Title: Name:

Position/Title: Name:

Position/Title:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 3 concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 4 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101)

1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State’s Medicaid plan (Title XIX); OR

1.1.3.

A combination of both of the above.

In May 1998, the Arizona legislature approved Senate Bill 1008 (Laws of 1998, Chapter 11) authorizing the implementation of a Title XXI Child Health Insurance Program. This program is referred to as KidsCare (see Attachment A). The passage of the legislation was the culmination of many meetings convened by Governor Jane Dee Hull and legislative hearings which provided a venue for the public to testify about the proposal. Additionally, staff from AHCCCS, Arizona’s Medicaid program, have met continually with interested parties to discuss the implementation of the program.

Arizona submitted a Title XXI State Plan to extend health care coverage statewide for children up to the age of 19. The effective date for the State Plan was October 1, 1997 which enabled the state to prepare for the implementation of the program. Actual services were rendered beginning November 1, 1998. Income thresholds were set at 150% of federal poverty level (FPL) at the beginning of the program. Beginning October 1, 1999 income levels were raised to 200% of the FPL. Arizona does not impose a resource test for this population. AHCCCS performs all KidsCare eligibility determinations for new applicants and redeterminations of eligibility based on a simplified eligibility process. A process has been implemented to determine whether a child is eligible for Medicaid prior to a determination of eligibility for KidsCare.

Arizona provides KidsCare services through established AHCCCS health plans which are referred to as contractors throughout this document.

All children have a choice of available contractors and primary care providers in a geographic service area. Additionally, Native Americans can elect to receive services through the Indian Health Service (IHS), 638 tribal facilities or one of the contractors. The KidsCare service package is the same service package offered

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 5 to Medicaid recipients. AHCCCS coordinates educational activities with the assistance of safety net providers, other state agencies, tribal entities and organizations, advocacy groups and other appropriate entities.

Copayments are assessed for all members, except Native Americans. In addition, families with income above 100% of FPL are assessed premiums. The total cost for premiums and copayments will not exceed 5 percent of the family income.

The number of children who are eligible for the program may be capped based on the available state and federal funding.

AHCCCS coordinates with other private and public programs which provide health care services to children. Arizona does not want to encourage employers or parents to discontinue current insurance coverage for children. Therefore, as a protection against “crowd out”, children must be without group health insurance for three months before eligibility will be granted for KidsCare.

The three month bar provision will be waived under the following circumstances: 1. Reached their lifetime insurance limit; 2. Are newborns; 3. Are transitioning Title XIX members; 4. Are applicants who are seriously or chronically ill; 5. Are Title XXI members who lose insurance coverage; 6. Are enrolled with Children's Rehabilitative Services; or 7. Are Native American members receiving services from IHS or a 638 Tribal Facility.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

AHCCCS assures that the expenditures for child health assistance are not claimed prior to the time that the state has legislative authority to operate the State plan or plan amendment as approved by CMS.

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 6 AHCCCS ensures that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35.

1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Original Implementation date: November 1, 1998

Amendment #9 Effective date: February 1, 2004 (premiums >150% FPL) July 1, 2004 (premiums 100%-150% FPL)

Amendment #12 Effective date: January 1, 2010 (KidsCare Enrollment Freeze)

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 7 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public- private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

When the KidsCare program was implemented, AHCCCS used the CPS methodology described in Attachment B. Since March 2000, AHCCCS has opted to use the CPS methodology to describe the manner and extent to which the children in the state targeted the low-income children and other classes of children, by income level and other relevant factors to make a distinction between creditable coverage under public health insurance programs and public private partnerships.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

The state is taking a number of steps to identify and enroll children who are eligible for public health insurance programs. The following describes these programs.

MEDICAID HEALTH INSURANCE

Arizona has several on-going major public efforts aimed at identifying, referring, and enrolling children in public insurance programs. Arizona currently has a an amendment to our 1115 Waiver enabling the state to cover persons up to 100% of the FPL, a HIFA Waiver for parents, and numerous public health programs that provide health care services to children.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 8 Formal referral processes are in place between governmental and community agencies which aid in the identification, referral and enrollment of uninsured children in the appropriate program. For example, by state law, children and pregnant women must be screened for Medicaid eligibility before applying for state-funded public programs or private programs. Coordination efforts have become even more critical since the implementation of KidsCare in November 1998.

As of May 1, 2002, AHCCCS health plans provided Medicaid services to 680,716 acute care Medicaid members and 34,334 long term care members enrolled in the Arizona Long Term Care System. Acute care members are individuals who enrolled with the AHCCCS health plans but not eligible for the Arizona Long Term Care System. Included in the acute care population are 73,713 Native Americans who elected to receive Medicaid services from the IHS. Arizona currently serves 371,267 children under the age of 19 through Medicaid. As of May 1, 2002, 48,212 children were enrolled in KidsCare.

The state has several agencies who perform eligibility functions. The Arizona Department of Economic Security (DES) processes applications and determines eligibility for Medicaid groups, except the SSI Cash, SSI- Medical Assistance Only (MAO) groups, the Medicare cost sharing programs, and ALTCS. For SSI-Cash, the Social Security Administration performs the eligibility determinations. AHCCCS performs eligibility for SSI-MAO, the Medicare cost sharing programs, and ALTCS. As mentioned in Section 1.1.3, AHCCCS determines KidsCare eligibility.

EFFORTS TO IDENTIFY AND ENROLL CHILDREN IN PUBLIC INSURANCE PROGRAMS

In addition to Medicaid, Arizona has five public initiatives which identify and help enroll children in programs that serve children. AHCCCS coordinates with these programs and initiatives to ensure that children who do not qualify for KidsCare are referred to other public and private programs.

Outstationed Eligibility Workers

Arizona has outstationed eligibility workers at some of the 14 Federally Qualified Health Centers (FQHCs), in hospitals which serve a disproportionate number of low income persons, and at five Arizona Department of Juvenile Corrections locations. At these outstationed sites, a person applying for Medicaid is assisted by an eligibility worker who submits a completed application to the appropriate eligibility office.

Model Application Template for the State Children’s Health Insurance Program

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Community Health Centers

Arizona has 32 community health centers that offer a wide range of health care services based on a sliding fee scale. Community health centers provide primary care services, including care for acute and chronic illnesses, injuries, family planning and prenatal care, emergency care and diagnostic services.

Maternal and Child Health Block Grant

Maternal and Child Health Block Grant funds are administered by the Arizona Department of Health Services (ADHS). This department funds, monitors and evaluates a variety of statewide community-based programs, which provide education and assistance for enrollment in public health insurance programs. These programs include: Healthy Start, High Risk Perinatal Programs, Pregnancy and Breast Feeding Hotline, Children’s’ Information Center, Reproductive Health, County Block Grant and Children’s’ Rehabilitative Services.

Children’s Rehabilitative Services

Funded by a Title V block grant, the ADHS/Children’s Rehabilitative Services (CRS) provides health care services to children with special health needs. Additionally, Medicaid eligible children receive services through CRS and AHCCCS reimburses ADHS with Medicaid funds for covered services provided by the program. A DES Family Assistance eligibility worker is located at each CRS site and field clinic to process applications for public assistance programs.

Indian Health Services (IHS) and Tribal Entities

There are three IHS Area Offices in Arizona: Phoenix, Tucson and Navajo. Each area office has a designated service delivery area in which IHS Service Units and health centers provide health care services to Native Americans, including those who are AHCCCS members.

There are three urban Indian Health Centers in Arizona. Each has a unique relationship with the IHS and receives an allotment from the IHS federal appropriation to provide health care services to Native Americans residing in Phoenix, Tucson and Flagstaff.

Tribal governments have established healthcare programs for tribal members. In general, the majority of these services are behavioral health

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 10 services and/or alcohol and substance abuse programs.

The Gila River Indian Community has opted to contract for the delivery of health care from the Phoenix Area IHS through the P.L. 93-638 contracting process. The Gila River Health Care Corporation is the tribal governing body which oversees the operation of the HuHuKam Memorial Hospital which is located on the Gila River reservation. The hospital provides primary health care services to tribal members and also operates an outpatient clinic on weekdays with scheduled appointments.

In addition, the Gila River Indian Community Department of Health, operates a Medicaid Early Periodic Screening Diagnosis and Treatment (EPSDT) program through an intergovernmental agreement with AHCCCS. This tribal program ensures that children receive the services required under the EPSDT program.

AHCCCS continues to look at ways of increasing enrollment of Native American families in both reservations and urban communities. The KidsCare News is a newsletter that provides information of special interest to the tribal communities. The AHCCCS Native American Coordinator is a key link between AHCCCS and the tribal community promoting communication and education to the members.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

STATE FUNDED PROGRAM Unlike some states, Arizona does not have public-private partnerships with insurers which offer child health insurance products. In 2002, the legislature authorized 100%state-funding for the working poor, with income up to 200 percent of FPL. Persons who are chronically ill as defined in rule, may have household income up to 400 percent of the FPL.

2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

Additional efforts by AHCCCS include the partnership with the Department of Education (DOE) to provide information to families

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 11 about KidsCare through the Child Nutrition Program (school lunch program). Due to the success of this partnership, AHCCCS plans to explore other methods to reach children through the schools.

AHCCCS has also partnered with small businesses and minority business companies in the community to disseminate information about the SCHIP Program.

AHCCCS has developed and implemented a universal application (Application for AHCCCS Health Insurance) to simplify the referral and eligibility processes for individuals and families when applying for SCHIP, Medicaid and state-funded programs. Users of this application include the general public, eligibility staff, hospitals, advocacy groups, community organizations and agencies. This application is also available on the Internet.

AHCCCS is partnering with a group of community health centers to demonstrate a web based eligibility application. Health-e-Arizona is a partnership between the Community Health Centers Collaborative Ventures, Inc. (CHCCV), AHCCCS and the Department of Economic Security (DES). Effective June 17, 2002, Health-e-Arizona is being piloted at El Rio Health Center. After a test period, Health-e-Arizona will be piloted at 7 CHCCV member organizations in 35 sites statewide. Deloitte Consulting, (who developed Health-e-App for the California HealthCare Foundation), worked with CHCCV, AHCCCS and DES to modify the application to meet Arizona’s requirements. Health-e-Arizona enables clinic workers to screen for Title XIX and Title XXI eligibility. Clinic workers will send completed applications, documentation and signatures electronically to AHCCCS and DES. This project was funded by CHCCV without Title XIX, Title XXI or state funds.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 12 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

AHCCCS administers the Title XXI KidsCare Program. The program uses Title XXI funding to provide targeted, low income children with a choice of one of the 10 prepaid, capitated AHCCCS health plans, the Indian Health Service and P.L. 638 tribal facilities.

AHCCCS HEALTH PLANS

In partnership with AHCCCS, the health plans have been delivering quality, managed care services for almost 20 years. Their commitment to quality management is evidenced by the fact that at least half of the contractors voluntarily have sought and received accreditation from the National Committee for Quality Assurance (NCQA). Please see Attachment E for a profile of the current health plans who participate in the KidsCare Program.

AHCCCS health plans have been very successful in assuring access to care. Over 89 percent of practicing physicians in the state participate in the program. Care is available in a wide range of settings, including FQHCs and many of the Rural Health Centers, who have elected to subcontract with the health plans.

AHCCCS health plans are held to the same standards for KidsCare that are required for the Medicaid program. In order to secure a contract to deliver Medicaid services, bidders must respond to a Request for Proposal (RFP) and submit a proposal with specific capitation rates for one or more of the nine geographic service areas in the state. A critical element in the bid evaluation performed by AHCCCS is an assessment of how each prospective contractor will meet all financial and operational requirements, ensure quality of care and provide a sufficient network to meet specified accessibility requirements. Following is a more detailed description of the elements which are scored during the RFP process: Program • Member Services • Quality and Utilization Management

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 13 • Early Periodic Screening Diagnosis and Treatment • Maternal Health/Women’s Health • Behavioral Health Services

Provider Network • Development of Capacity • Management and Oversight

Organization • Organization and Staffing • Fraud and Abuse • Subcontracts • Claims and Third Party Liability • Liability Management • Grievance and Appeals • Financial Standards • Encounters

Capitation Rates • All offerors submit detailed capitation bids which are evaluated against actuarially sound rate ranges. For the KidsCare Program, AHCCCS sets the rates based on an actuarial analysis.

Ongoing Monitoring

AHCCCS monitors the solvency of the health plans and their delivery of health care services with the following activities:

Quarterly and annual financial reporting • On-site annual operational and financial reviews • Performance measures using administrative data and medical records • Member surveys • Network reporting • Encounter validation studies to determine completeness, accuracy and timeliness • Solvency standards • Coordination of benefits • Educational efforts • Medical studies • Frequent meetings with contractors’ executive management

Other Intergovernmental Agreements

Model Application Template for the State Children’s Health Insurance Program

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In addition to amending health plan contracts, AHCCCS has amended the current Intergovernmental Agreements with the ADHS for behavioral health services and children’s rehabilitative services, and the DES for KidsCare services provided to foster care children. Amendments with ADHS are necessary to provide behavioral health services through the Regional Behavioral Health Authorities for the KidsCare population and to reimburse ADHS for services provided to KidsCare eligible special needs children who are also enrolled in the CRS program. The amendment with DES is necessary to direct foster children eligible for KidsCare to the Comprehensive Medical and Dental Program, which is the current health plan for foster care children.

Indian Health Services/638 Tribal Facilities

AHCCCS also enables KidsCare eligible Native American children to use the Indian Health Service or 638 facilities operated by tribal governments who want to participate in the program. Of course, a Native American child who is eligible for KidsCare may also elect to enroll with one of the available AHCCCS health plans or a participating state employee HMO.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

AHCCCS has a managed care system that relies on multiple strategies to provide appropriate and medically necessary services. Children enrolled in the KidsCare Program have a choice to enroll with any of the available contractors in their geographic service area, including Indian Health Services, and have the right to choose a primary care provider (PCP) from the available practitioners. The PCP is contractually responsible for coordinating the care of members and approving referrals for medically necessary specialty services.

The AHCCCS Medical Policy Manual (AM/PM), which is available to all contractors and providers, specifies covered and excluded services under the KidsCare Program, as well as prior authorization (PA) requirements.

Each contractor is responsible for maintaining a utilization management program which includes: medical claims review, concurrent review, inpatient discharge planning, profiles of individual providers, drug utilization monitoring, analysis of durable medical equipment orders and non-emergency prior authorization.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 15 Contractors must have a 24-hour telephone number staffed by health care professionals who advise members about the appropriate use of the emergency room and how to use urgent care centers. KidsCare members are subject to a $5.00 copayment when Emergency Departments are utilized for nonemergency services, in order to discourage inappropriate use of these facilities.

AHCCCS reviews and monitors contractors’ utilization management through an analysis of their financial reporting, through on-site operational and financial reviews and reviews of the utilization reports and the annual utilization management plan submitted by the contractors. These tools are discussed further in Section 7.1.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 16 Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 5.

4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a))

4.1.1.

Geographic area served by the Plan: Statewide. 4.1.2.

Age: KidsCare is available to children under 19 years of age. A child is considered to be under age 19 through the day before the child's 19th birthday. Coverage will continue through the month in which the child turns age 19. 4.1.3.

Income: The combined gross income of the family household members may not exceed 200% of the FPL. As required by CMS, certain payments and grants as specified in 20 CFR Part 416, the Appendix to Subpart K, are excluded when determining gross income. All wages paid by the Census Bureau for temporary employment related to census activities are excluded.

See Attachment G for a description of family household income and the methodology for evaluating family income. 4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): No Resource Test. 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): Arizona residency is required. An Arizona resident is a person who currently lives in Arizona and intends to remain in the state indefinitely. AHCCCS requires a signature on the application declaring that the child is an Arizona resident. 4.1.6.

Disability Status (so long as any standard relating to disability status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: A child is not eligible for KidsCare if the child is: • Eligible for Medicaid. • Covered under an employer’s group health insurance plan. • Covered through family or individual health care coverage.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 17 • Eligible for health benefits coverage under a state health benefits plan on the basis of a family member’s employment with a public agency (see Attachment H). • Covered under an employer’s group health insurance plan or by private insurance within the last three months and the health insurance coverage was terminated for a reason other than involuntary loss of employment. This exclusion does not apply to persons with group health insurance who resigned from employment to avoid termination of employment. This exclusion also does not apply to children who: 1. Reached their lifetime insurance limit; 2. Are newborns; 3. Are transitioning Title XIX members; 4. Are applicants who are seriously or chronically ill: 5. Are Title XXI members who lose insurance coverage; 6. Are enrolled with Children's Rehabilitative Services; or 7. Are Native American members receiving services from IHS or a 638 Tribal Facility. 4.1.8.

Duration of eligibility: • Fails to cooperate in meeting the requirements of the program; • Cannot be located; • Attains the age of 19. • Is no longer a resident of the state; • Is an inmate of a public institution; • Is enrolled in Medicaid; • Is determined to have been ineligible at the time of approval; • Obtains private or group health insurance; • Is adopted and no longer qualifies for KidsCare; • Is a patient in an institution for mental diseases; or • Voluntarily withdraws from the program. KidsCare members are notified on the approval notice of the requirement to report changes that affect eligibility. Ineligibility due to excess income does not affect the initial 12 months of continuous coverage. 4.1.9.

Other standards (identify and describe): Citizenship or Qualified Alien Status. A child must be a United States citizen or a qualified alien. Unless one of the exceptions listed in P.L. 104-193 is applicable, a child who is a qualified alien who entered the United States on or after August 22, 1996 is not eligible for KidsCare until five years after the child became a qualified alien.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 18 Assignment of Rights. Under Arizona law, assignment of payments for medical care from any first or third party occurs when the application is signed. Assignment is explained on the application form.

Social Security Number. The application for KidsCare is a joint application for Medicaid and KidsCare. AHCCCS requests a Social Security Number on the KidsCare application but does not deny eligibility for KidsCare due solely to the failure to provide a Social Security Number or refusal to apply for a Social Security Number. However, if the financial screening determines that the child would be eligible for Medicaid if an application were processed and the child, or responsible party, refuses to apply for a Social Security Number necessary to complete the Medicaid application, AHCCCS denies the KidsCare eligibility. Please see the requirement in Section 4.4.2.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350)

The following describes the methods of establishing and continuing eligibility and enrollment. The child, a family member or legal guardian, fills out a simple application form, which is submitted, to AHCCCS. If assistance with the application is needed, appropriate personnel assist the applicant. The form also serves as an application for Medicaid.

AHCCCS has published the application form and instructions for completing the form in English and Spanish. Based on the demographics in Arizona of other ethnic groups, AHCCCS does not believe that developing the application in other languages is necessary since no other ethnic group exceeds 3% of the population. However, an interpreter is provided, if needed.

AHCCCS completes an eligibility determination for KidsCare applications within

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 19 30 days from the date of receipt of a signed, completed application in an AHCCCS eligibility office except in unusual circumstances. One example would be when the agency can not reach a decision because the applicant failed to provide required information or take required action.

When information needed to make an eligibility determination is not submitted with the application, AHCCCS sends a notice to the applicant or the representative outlining the information required and the time frame for providing the information. AHCCCS gives applicants ten calendar days to provide any information necessary to enable AHCCCS to determine the applicant's eligibility. Applicants must choose a health plan or the IHS before enrollment into the KidsCare Program. Written materials about the various health plans and their toll-free telephone numbers are available with the application form. In addition, the covered services are outlined in the written materials. If a Native American selects the Indian Health Service or a tribal facility, AHCCCS provides any KidsCare services not provided by these entities on a fee-for-service basis off-reservation.

The KidsCare providers are:

• AHCCCS health plans, which includes Comprehensive Medical and Dental Program (CMDP) for foster care children. • For Native Americans, any of the above or the Indian Health Service or a 638 tribal facility.

For eligibility determinations completed by the 25th day of the month, KidsCare eligibility begins with the first day of the month following the month in which the child is determined to meet the eligibility criteria for the program. Children who are determined eligible for the program after the 25th day of the month are eligible for the program the first day of the second month following the determination of eligibility.

Once the application is approved, the applicant is enrolled with their chosen provider and AHCCCS sends a notice confirming the choice and a member identification card to the member. Following enrollment, the contractor provides a member handbook to the member, which contains important information about how to access health care for KidsCare eligible children.

AHCCCS approves a newborn of a mother who is eligible for KidsCare on the date the child is born and enrolled in the KidsCare Program. The newborn’s KidsCare eligibility begins with the newborn’s date of birth. Prior to approval, the agency contacts the mother by telephone to reverify household composition and

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 20 monthly income. Once approved for KidsCare, AHCCCS enrolls the newborn with the mother’s health plan. AHCCCS notifies the mother by mail of the newborn’s enrollment into KidsCare and is given an opportunity to change health plans at that time.

If a member of a family is enrolled in KidsCare and another child is born to the family, AHCCCS enrolls the newborn in KidsCare if the family income meets the KidsCare criteria. Eligibility is prospective. The same process applies to a child who may be reunited with a family.

A member is allowed to change contractors on an annual basis and when an individual moves into a new geographic area not served by the current contractor. A member can change PCPs at any time. The option to change contractors is based on the member’s anniversary date, which is the first day of the month that the member is enrolled into KidsCare. Ten months following the anniversary date, the member will be sent an annual enrollment notice advising that a different contractor may be selected. A list of contractors, with toll-free numbers and the available services, is included. The member, or parent of the child, has three weeks to change contractors. If a change is requested, the effective date is a year from the anniversary date. Enrollees must notify AHCCCS of a change in address or other circumstances that could affect continued eligibility or enrollment.

Children who elect to enroll with IHS or a 638 tribal facility are allowed to disenroll at any time upon request and choose a contractor for all KidsCare services. Similarly, Native American children enrolled with a contractor or other provider, are allowed to disenroll at any time upon request and enroll with the IHS.

4.3.1 Describe the state’s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Check here if this section does not apply to your state.

Due to insufficient state funds, an enrollment freeze has been placed on the KidsCare program effective January 1, 2010. The program will place individuals on a waiting list and no new applications will be processed until such time that the AHCCCS Administration is able to verify that funding is sufficient, and the Governor agrees that the AHCCCS Administration may begin processing new applications.

Despite the KidsCare enrollment freeze, applications will continue to be evaluated and processed for potential Medicaid eligibility. If a child does not meet the Medicaid eligibility requirements, the authorized representative of

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Approval Date: 21 the child will be notified in writing of the denial of Medicaid and will also be notified of the denial of KidsCare due to the enrollment cap. The notice will also state that the child will be placed on a waiting list for KidsCare.

Children who have current enrollment in the KidsCare program will be allowed to continue to renew their enrollment so long as they continue to meet all the eligibility and renewal criteria including timely premium payments.

When sufficient funding becomes available and the Governor agrees that the AHCCCS Administration may begin processing new applications, the Administration shall contact an applicant on the waiting list and ask the applicant to submit a new application if the original application is more than 60 days old. The Administration shall fill spaces in the order that an application is received and approved. In the event the enrollment freeze is lifted, public notice will occur using the methods described above for the implementation of the freeze. CMS will also be notified in writing.

4.4. Describe the procedures that assure that:

4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including a state health benefits plan) are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A)) (42CFR 457.350(a)(1) and 457.80(c)(3))

AHCCCS ensures that a child who is not eligible for Medicaid, but who meets KidsCare eligibility criteria, is enrolled in KidsCare. AHCCCS administers both the Medicaid and KidsCare Program. Medicaid screening is part of the KidsCare eligibility determination process. Records of KidsCare eligibility are maintained in a database that is also used for Medicaid eligibility. The database is checked for current Medicaid eligibility before determining KidsCare eligibility. Medicaid eligibility always overrides KidsCare eligibility.

AHCCCS accepts a declaration on the application confirming that there is no other creditable insurance including the state health benefits plan. A family member, legal representative or the child is required to report changes in employer insurance coverage or eligibility for group health insurance or other creditable insurance.

When conducting a renewal (periodic redetermination) of KidsCare

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Approval Date: 22 eligibility, AHCCCS screens for potential Medicaid eligibility, group health plan, health insurance coverage, or other state health benefits. If a child appears to meet the Medicaid eligibility criteria, AHCCCS forwards a copy of the renewal application and all obtained verification to the Department of Economic Security staff for an eligibility determination. For review of potential group health plan coverage see section 4.4.4.1.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

As stated in subsection 4.4.1, AHCCCS administers both Medicaid and the KidsCare Program and ensures that any child eligible for Medicaid is enrolled in Medicaid. The application form used for KidsCare initiates an application for Medicaid, which is determined simultaneously. Medicaid eligibility always overrides KidsCare eligibility.

If a child appears to meet Medicaid eligibility criteria, AHCCCS forwards a copy of the application and all obtained verification to the Department of Economic Security staff for an eligibility determination. Prior to a full Medicaid determination, AHCCCS enrolls the child into KidsCare. If the child is approved for Medicaid, AHCCCS claims Medicaid funding, rather than KidsCare funding, back to the date of Medicaid eligibility which generally is prior to the KidsCare eligibility effective date.

If the KidsCare staff screen a child both Medicaid and KidsCare ineligible, they forward the application to the AHCCCS Central Screening Unit (CSU). The CSU reviews the application and makes a full Medicaid eligibility determination. If the child is ineligible for Medicaid due to income, the CSU sends notification of the decision to the family.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

In addition to the process described in subsection 4.4.1., the Department of Economic Security sends information daily to AHCCCS on children who lose their Medicaid coverage due to increased income. If eligible, AHCCCS approves the children for KidsCare.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 23 appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

The application requests information about group health plan coverage within the past three months. If a child is covered by group health insurance or was covered and the coverage was voluntarily discontinued, the child is not eligible for KidsCare for a period of three months unless the child has exceeded the lifetime limit to his or her insurance policy. AHCCCS grants exceptions to the three month period of ineligibility as discussed in 4.1.7.

AHCCCS monitors substitution under its Quality Control and Quality Assurance process to analyze the extent to which an applicant drops other health plan coverage. Records are reviewed to ensure that the three month period of ineligibility policy is applied appropriately. Action is taken as needed. Trends are monitored to ensure that the policy is consistantly applied throughout the program.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable.

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

4.4.4.4. If the state provides coverage under a premium assistance program, describe:

The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period.

The minimum employer contribution.

The cost-effectiveness determination.

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Approval Date: 24 4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

Meetings to discuss the KidsCare Program and education strategies have been and continue to be held with representatives from the three area IHS agencies, the Arizona Inter-tribal Council, which represents 20 of Arizona’s 21 Indian Tribes, the Navajo Nation, Urban Indian Centers and the Indian Health Advisory Committee. In addition, the Governor’s Office convened a meeting to discuss the KidsCare Program and invited representatives from the 21 tribes See Attachment I for a listing of the tribal entities who have participated in the discussions.

As discussed in Section 3, IHS and participating 638 tribal facilities may provide KidsCare services. In addition, Native American children may choose to enroll with a contractor in their geographic area.

Applications and enrollment information are available at IHS and appropriate tribal locations. AHCCCS also uses Native American events, newspapers, and radio stations as a forum for outreach. If IHS or tribal staff are willing to assist applicants in completing the application for AHCCCS health insurance, AHCCCS provides training.

AHCCCS has a Native American Coordinator who is available to the tribes for consultation, information and presentations.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 25 Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish:

Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

Arizona has designed a very effective educational program with the community to inform families about the availability of KidsCare and assist children with enrollment in the KidsCare Program. To accomplish these two goals, Arizona has established numerous coordination procedures as required by Title XXI.

Prior to implementation of KidsCare in 1998, the Governor’s Outreach Work Group, with representatives from the following agencies/organizations, met several times to develop a comprehensive education plan:

AHCCCS Arizona Association of Community Health Centers Arizona Chapter of Academy of Pediatrics Arizona Children’s Action Alliance Arizona Children’s Association ADHS/Community and Family Health Services AHCCCS Contractors Arizona Prenatal Care Coalition Inter-tribal Council Phoenix Children’s Hospital Participating Indian Tribes

The Governor’s Office and AHCCCS worked collaboratively with tribal entities to inform Native American families about the availability of KidsCare and to assist in enrolling children in KidsCare. Please refer to Section 4.4.5 for a description of the Native American activities.

These efforts by AHCCCS have modeled successful methods used by other child-related programs (Maternal Child Health Block Grants and Women, Infants and Children Program [WIC]). The distribution of applications is targeted to those agencies, organizations and other entities who currently serve low income children. These efforts include providers for children with special health care needs and traditional safety net providers such as:

Arizona Chapter of Academy of Pediatrics, including the Medical Home

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Approval Date: 26 Project

ADHS which administers: • Children’s Rehabilitative Services • Family Planning • Healthy Start • Immunization Sites • Maternal Child Health • WIC

Arizona Interagency Farmworkers Coalition

Big Brothers/Big Sisters

Community Family Services Agencies

Community Based Clinics (27, of which 14 are FQHCs)

Community Legal Services

County Health Departments

DES which administers: • TANF • Food Stamps • Community Services Assistance • Unemployment Insurance • Job Services • Child Support Enforcement • Services for persons with developmental disabilities • Children Youth and Families Services

Family Crisis Centers

Food Banks

Federation of Teachers

Headstart Programs, including Migrant Headstart program

Homeless Shelters

Hospitals

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 27

Indian Health Service

Inter-tribal Council

Other advocate groups

Preschool/Special Education

Professional associations (e.g., local medical and dental)

Schools

Social Security Administration

Arizona Department of Juvenile Corrections

State Education Association

Subsidized Housing Agencies

Tribal health care and social service programs

YMCA/YWCA.

AHCCCS, and other interested parties, have developed strategies that are culturally sensitive to Arizona’s diverse population, including the translation of materials in English and Spanish. These strategies include, but are not limited to the following: • Mass media • Radio • Television advertisement • Brochures • Posters • Flyers • Video

A referral hotline and information number (1 877-764-KIDS (5437)

Training community advocacy groups regarding assistance to families in the completion of the universal application (Application for AHCCCS Health Insurance)

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 28 Statewide community information forums

Information sharing with foundations (The Flinn Foundation and St. Luke’s Charitable Trust)

Collaboration with minority health groups

Partnerships with various agencies, municipalities, community organizations and ecumenical groups

In addition to the strategies identified above, informational materials are distributed through:

AHCCCS participating doctors (approximately 89 percent of all physicians in Arizona) • Faith organizations • Community centers • Day care centers • Grocery stores • Other medical providers, such as hospitals and pharmacies • Public health offices • Schools • HUD • Other appropriate locations

Education regarding the KidsCare Program conducted through collaborative arrangements with other state, county and city agencies as well as programs that conduct education in rural and inner-city areas.

Efforts are designed to inform families about the availability of the KidsCare program, provide basic information about eligibility and instruct families about how and where to apply for the program. Information about Medicaid and the state-funded programs is included as part of the overall strategy for enrollment.

Organizations distributing the applications and information about KidsCare are provided training as needed to assist with completing the application form and collecting information as necessary.

An applicant may also receive assistance to complete the application form by calling the KidsCare Office at their statewide toll free number, 1-877-764- KIDS (5437). The applicant is assisted by an AHCCCS staff person who:

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Approval Date: 29 • Explain the application process, including those items, which will require verification. • Explain enrollment and choice. • Obtain the necessary information to fill out the application. • Mail the application and enrollment packet to the applicant for review, signature and supply any required verification.

Applications may be mailed to the AHCCCS KidsCare Office for an eligibility determination. Applications are tracked by source and disposition code, and efforts are modified based on this data.

To specifically target low income children of migrant workers, the Arizona Interagency Farmworkers Coalition has agreed to include information about KidsCare in their newsletters. The Coalition has relationships with a number of the prominent growers in the state who employ farmworkers. Through the Coalition, AHCCCS is given the opportunity to distribute KidsCare and Medicaid outreach materials with paychecks issued to the farmworkers.

The farmworkers typically rely on the WIC program, Headstart programs, FQHCs and other community-based clinics. Each of these will be actively involved in the KidsCare education campaign.

In addition, any individual interested in learning about KidsCare may call the main AHCCCS toll-free hotline number 24 hours a day, 7 days a week or the KidsCare hotline number to learn more about the program and how to apply for services

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 30 Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1. Coverage the same as Medicaid State plan

Arizona uses the same benefits as are provided under the Medicaid State plan. Any limitations on the covered services are discussed in this section

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 31 and are delineated in the AHCCCS Medical Policy Manual. The cost sharing requirements are specified in Section 8 of the State Plan. Members who enroll in the KidsCare Program who select an AHCCCS health plan will receive the

KidsCare services, subject to the limitations described in subsection 6.2.

6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe)

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.1.

Inpatient services (Section 2110(a)(1))

a. Inpatient hospital services, including medically necessary ancillary services, and emergency hospital services, if furnished by a licensed hospital and provided by or under the direction of a PCP or primary care practitioner according to federal and state law, rules, and AHCCCS Policies and Procedures. Inpatient hospital services include services provided in an institution specializing in the care and treatment of members with mental diseases. b. Services in an Institution for Mental Diseases (IMD) when the member requires services in an inpatient psychiatric hospital. IMD are available to members who are determined to require these services after enrollment in KidsCare. However, applicants

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 32 in an IMD at the time of application are excluded from enrollment in KidsCare.

Medically necessary transplant services, which are not experimental, if provided to correct or ameliorate disabilities, physical illnesses or conditions. Transplantation services are authorized in accordance with AHCCCS transplantation policies.

6.2.2.

Outpatient services (Section 2110(a)(2))

Outpatient hospital services ordinarily provided in hospitals, clinics, offices and other health care facilities by licensed health care providers. Outpatient hospital services include services provided by or under the direction of a PCP or primary care practitioner or licensed or certified behavioral health professional according to federal and state law.

6.2.3.

Physician services (Section 2110(a)(3))

Physician services if provided by or under the direction of a PCP, psychiatrist, or under the direction of a primary care practitioner according to federal and state law. Services are covered whether furnished in the office, the member’s home, a hospital, a nursing home or other setting.

Only psychiatrists, psychologists, certified psychiatric nurse practitioners, physician assistants, certified independent social workers, certified marriage/family therapists, and certified professional counselors may bill independently for behavioral health services. Other behavioral health professionals, behavioral health technicians and behavioral health paraprofessionals shall be affiliated with, an AHCCCS registered behavioral health agency and services shall be billed through that agency.

6.2.4.

Surgical services (Section 2110(a)(4))

Medically necessary surgical services under inpatient and outpatient services (Sections 6.2.1 and 6.2.2).

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

a. Outpatient services (Section 6.2.2).

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Approval Date: 33 b. Ambulatory services offered by a health center receiving funds under section 330 of the Public Health Services Act. c. Rural health clinic services and federally qualified health center services and other ambulatory services.

6.2.6.

Prescription drugs (Section 2110(a)(6))

a. Pharmaceutical services provided to a member if prescribed by the attending physician, practitioner, or dentist. b. Prescription drugs for covered transplantation services provided according to AHCCCS transplantation policies.

c. Generally, medications dispensed by a physician or dentist are not covered.

6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

Laboratory, radiological and medical imaging services.

6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

a. The following family planning services: • Contraceptive counseling, medication, supplies and associated medical and laboratory exams • Natural family planning education or referral b. Infertility services and reversal of surgically induced infertility are not covered services. c. Family planning services do not include abortion or abortion counseling.

6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

a. Inpatient behavioral health services, other than inpatient and residential substance abuse treatment services, but including services furnished in a state operated mental hospital and including residential or other 24-hour therapeutically planned structured services. b. Services in a state operated mental hospital (e.g., Institution for Mental Diseases). IMD services are only available to members who are determined to require these services after enrollment.

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Approval Date: 34 Applicants who are receiving IMD services at the time of application are excluded from enrollment in KidsCare.

c. Partial care services are included as part of the inpatient benefit.

6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services (Section 2110(a)(11)

a. Outpatient behavioral health services, other than substance abuse treatment services, including services furnished in a state operated mental hospital (e.g., IMD) and community- based services. b. Outpatient behavioral health services includes individual and/or group counseling/therapy, rehabilitation services, including basic and intensive partial care, emergency/crisis services, behavior management, psychosocial rehabilitation, evaluation and behavioral health related services.

6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

See Section 6.2.17--Dental services for coverage of dental devices. Vision services include prescriptive lenses.

6.2.13.

Disposable medical supplies (Section 2110(a)(13))

Medical supplies include consumable items that are disposable and are essential for the member’s health.

6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15))

a. Private duty nursing care, respiratory care services, and services provided by certified nurse practitioners in a home or other setting. b. Certified nurse midwife services when they are rendered in collaboration with a licensed physician or PCP or primary care practitioner in accordance with AHCCCS Policies and Procedures.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 35 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

A physician shall provide written certification of necessity of abortion.

6.2.17.

Dental services (Section 2110(a)(17))

a. Dental services, including routine, preventive, therapeutic and emergency services. b. Dentures and dental devices are covered if authorized in consultation with a dentist.

6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Inpatient substance abuse treatment is limited to acute detoxification.

6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19))

a. Refer to coverage under 6.2.11 - Outpatient mental health services, subject to the limitations prescribed in that section. b. Rehabilitation services provided by a substance abuse rehabilitation agency that do not exceed 30 outpatient visits for each 12-month period of eligibility.

6.2.20.

Case management services (Section 2110(a)(20))

Case management for persons with developmental disabilities.

6.2.21.

Care coordination services (Section 2110(a)(21))

Care coordination are available through contractors, primary care providers and behavioral health providers.

6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

Therapy services are covered when necessary to prevent or ameliorate a condition, illness or injury, to prevent or correct

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 36 abnormalities detected by screening or diagnostic procedures or to maintain a level of ability.

6.2.23.

Hospice care (Section 2110(a)(23))

Hospice services for a terminally ill member.

6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24))

a. Services provided in a facility, home, or other setting if recognized by state law. b. Respiratory therapy. c. Eye examinations for prescriptive lenses. d. Immunizations, preventive health services, patient education, age and gender appropriate clinical screening test and periodic health exams.

6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26))

Emergency ambulance and non-emergency transportation are covered services when the transportation is medically necessary.

6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

All printed materials are in English and Spanish. Outreach services will be available through AHCCCS, and others as specified in Section 4.4.5 and Section 5.

6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

1. Nursing facility services in a nursing facility or in an alternative residential setting for a maximum of 90 days when the medical condition of the person indicates that these services are necessary to prevent hospitalization. 2. Total parenteral nutrition services. 3. Podiatry services and optometrist services if furnished by a licensed podiatrist or optometrist, respectively.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 37 4. Other practitioner’s services are covered and include services provided by: a. Respiratory Therapists b. Certified Nurse Practitioners c. Certified Nurse Anesthetists d. Physician Assistants e. Nonphysician behavioral health professionals if the services are provided by social workers, physician assistants, psychologists, counselors, registered nurses, certified nurse practitioners, behavioral health technicians and other approved therapists who meet all applicable state standards. Except for behavioral health services provided by psychologists, psychiatric nurse practitioners, physician assistants, certified independent social workers, certified marriage/family therapists, and certified professional counselors, all nonphysician behavioral health professional services shall be provided by professionals affiliated with an approved behavioral health setting in accordance with rules and AHCCCS policies and procedures. 5. Home health services a. Home health services when necessary to prevent re- hospitalization or institutionalization, and may include home health nursing services, therapies, personal care, medical supplies, equipment and appliances and home health aide services. b. Nursing service and home health aide if provided on an intermittent or part time basis by a home health agency. When no home health agency exists, nursing services may be provided by a registered nurse. c. Therapy services. Covered services are required to be authorized by the appropriate entity, unless otherwise indicated. Authorization by an appropriate entity shall be performed by at least one of the following: a PCP, primary care practitioner, or behavioral health professional as required by rule and AHCCCS policies and procedures. The appropriate entity shall authorize medically necessary services in compliance with applicable federal and state laws and regulations, AHCCCS policies and procedures and other applicable guidelines.

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 38 2102(b)(1)(B)(ii)); OR 6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4. Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)):

6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b))

6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b))

6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F)

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 39 or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b)) 6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 40 Section 7. Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

The KidsCare Program uses performance measures, quality standards, information strategies and quality improvement studies to assure high quality care for members. The tools include:

• Quality standards defined in policy and contract • Annual on-site operational and financial reviews • Performance indicator and utilization measurement studies • Compliance with national quality measures

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.

Quality standards

Each contractor adheres to specific quality/utilization standards established by AHCCCS for the KidsCare Program. A comprehensive plan prepared by the contractor includes the following components: • Program monitoring • Program evaluation • Member education • Provider education • Compliance with mandatory components of preventive care visits.

Contractors participate in an annual review of the KidsCare program which includes on-site visits by AHCCCS staff to contractors and medical record audits.

AHCCCS monitors compliance with quality assurance standards through an established process of operational and financial reviews for the Medicaid program. The reviews are conducted by a review team comprised of AHCCCS staff. The reviews are performed on- site through interviews with appropriate personnel and through

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Approval Date: 41 review of documentation in the following areas:

• Administration and Management • Provider Services/Network Management • Grievance and Appeals • Medical Management • Quality/Utilization Management • Dental Services • Maternal Health/Family Planning • Behavioral Health • Delivery System and Access to Care Standards • Member Services • Financial

The review tool contains standards from the review areas identified above and provides the basis for assessing contractor performance, as well as identifying areas where improvements can be made or where there are areas of noteworthy performance and accomplishment.

7.1.2.

Performance measurement

AHCCCS requires contractors to meet the AHCCCS performance measures which are defined using HEDIS methodology as a guide. In particular, performance measurement will focus on the following areas:

• Age appropriate childhood immunizations • Dental visits • Well child visits in the first 15 months of life • Well child visits in the third, fourth, fifth, and sixth year of life • Access to a regular source of primary care

Indicator Summary Description 1. Childhood Immunization Rate The percent of members age two who were continuously enrolled for 12 months and received recommended immunizations. 2. Annual Dental Visit The percent of members age 3-19 with at least one dental visit in the reporting year. 3. Well Child Visits Under The percent of children age 15 months who

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 42 15 Months received all recommended well child visits during the reporting year. 4. Well Child Visits for 3, 4, 5 and 6 Year Olds The percent of children 3-6 who received a well child visit during the last year.

7.1.3.

Information strategies

All contractors must inform new members about services within ten days of enrollment. Information includes: • Benefits of preventive care • A complete description of services available • How to obtain these services and assistance with scheduling of appointments • A statement regarding copayments which may be required

In addition, both eligibility workers and contractors are required to educate KidsCare Program enrollees about their benefits, rights and responsibilities. This education focuses on the importance of preventive services, such as immunizations and dental visits, health promotion activities and the importance of regular visits to their primary care provider instead of using the emergency room for primary care.

7.1.4.

Quality improvement strategies

AHCCCS began a Quality Improvement Initiative in 1995 designed to use encounter data to monitor quality and to test new concepts of quality of care based on many of the recommendations for measurement from the Quality Assurance Reform Initiative (QARI) and the National Committee for Quality Assurance. The major components of the Initiative include:

Performance Measures as listed in subsection 7.1.2.

Financial Measures of health plan fiscal viability, management of care, timely payment of claims and documentation of medical expenses.

Member Satisfaction Surveys conducted to provide information on access to care, communication between members and providers, and quality of care.

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Approval Date: 43 Provider Satisfaction Surveys designed to assess primary care practitioners' satisfaction with the KidsCare Program.

In the future, the Consumer Assessment of Health Plans Survey (CAHPS) data may be incorporated into AHCCCS’ Quality Improvement Initiative, as well as any new reporting requirements which may be developed.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a))

Effective October 1, 2001 Kidscare members are eligible for the same services covered for members under the Title XIX program, as specified in the acute-care renewal contract.

The AHCCCS Medical Policy Manual further specifies that KidsCare services must be provided according to community standards and standards under Title XIX for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) enrolled members. This ensures access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations.

The AHCCCS Medical Policy Manual also states that, "Contractors must comply with all Quality Management and Quality Improvement requirements." Acute-care contractors are encouraged to include in their EPSDT annual plans and quarterly progress reports activities that will ensure access to services by KidsCare members and/or acknowledge that EPSDT activities apply to both Title XIX and Title XXI members. These reports include monitoring and evaluation of utilization of services.

Members enrolled under the KidsCare Program are included in analysis of the AHCCCS acute-care Performance Indicators for well-child and dental visits. Title XXI members are reported separately for immunizations and children's access to PCPs. The KidsCare population also is included in medical audits, as appropriate.

Additional monitoring is accomplished through the OFR process.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b))

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Approval Date: 44

AHCCCS requires all contractors to have sufficient provider capacity to absorb the additional KidsCare enrollment. Currently, all AHCCCS members have a choice of at least two contractors.

Contractors are required to meet the AHCCCS contractual standards for network capacity for primary care providers (PCPs). These standards include appointment availability, geographic accessibility, quality and utilization. AHCCCSA informs all health plans when a PCP, contracted with more than one contractor, exceeds 1800 AHCCCS members in their panel. This allows the health plans to more closely monitor these PCPs’ adherence to the standards. All Contractors have a system in place to monitor and ensure that each member is assigned to an individual PCP and that PCP assignment data is current. Members are allowed to choose their initial PCP from the health plan network and change the assignment should they wish to do so.

In addition, KidsCare enrollees are assured access through existing AHCCCS standards for appointment standards for emergency, urgent and routine care, specialty providers, and dentists.

Contractors provide emergency services facilities adequately staffed by qualified medical professionals to provide emergency care on a 24-hour per day, 7-day per week basis for treatment of medically emergent conditions. Contractors must educate members about the appropriate utilization of emergency room services and monitor utilization by both members and providers.

AHCCCS, through its operational and financial reviews, monitors contractor compliance with these standards. The health plans are also required to submit a description of their networks to the Agency on a quarterly basis.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

Contractors must follow care coordination policies set forth in of the AHCCCS Medical Policy Manual. These requirements include policies and procedures for identifying members with complex, serious and/or at- risk medical conditions, assessing those conditions, identifying medical

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Approval Date: 45 procedures to address and/or monitor the conditions, ensuring adequate care coordination among providers, and developing a plan of care appropriate to those conditions. The care plan must eliminate barriers to direct access to specialists, provide adequate access to support services, be time-specific, and be updated periodically.

Children with certain chronic, complex, or serious medical conditions receive services related to those conditions through the Children's Rehabilitative Services (CRS) program administered by the Arizona Department of Health Services. Contractors refer members who are potentially eligible for CRS services to the program for evaluation and enrollment if eligible. Contractors are required to monitor referrals to CRS and ensure that CRS-covered services are provided in a timely manner to eligible children. PCPs are required to coordinate care with CRS and to include those services in the member's medical record.

PCPs are accountable for maintaining a medical record which incorporates documentation of all health care services provided to assigned members, including PCP services, specialty medical and/or behavioral health services, all medications prescribed by the PCP and/or other providers, authorized durable medical equipment, dental services, emergency care, and hospitalizations, as required in the AHCCCS Medical Policy Manual. Contractors monitor PCP compliance with medical record keeping requirements through regular chart audits.

Contractors must ensure that appointments standards are met for specialty referrals within the following timeframes: emergency, within 24 hours of referral; urgent, within three days of referral; and routine, within 45 days of referral. Contractors monitor provider compliance with appointment standards through "secret shopper phone calls or regular/periodic on-site visits."

Indian Health Services and 638 Tribal Facilities are responsible for maintaining continuity of care and maintaining a complete medical record for each assigned member, as well as providing necessary referrals for specialty care.

AHCCCS monitors and assesses contractors' care coordination and case management processes, including referral to Children's Rehabilitative Services (CRS) and behavioral health services, through the Operational Financial Reviews (OFRs). Contractor compliance with appointment availability standards and QM/QI requirements also are evaluated in the OFRs.

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Approval Date: 46 7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

The state complies with this requirement of decisions related to the prior authorization of health services. The timeframe for prior authorization of decisions is the same in SCHIP as in the Medicaid program.

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 47 Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505)

8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c))

8.2.1. Premiums:

On October 1, 1999, AHCCCS began imposing monthly premiums on families whose income exceeded 150 percent of the FPL.

AHCCCS worked collaboratively with KidsCare stakeholders to develop the premium billing proposal based on these goals: • Insure more children. • Promote accountability and responsibility. • Notify KidsCare members of their premium rights and responsibilities. • Reduce administrative costs and implement a simplified system. • Have a process that is clear and understandable to the members.

The following is the premium billing and collection process: • Payments are accepted on a monthly basis. • The cost sharing methodology does not favor children from families with higher incomes over families with lower incomes. • AHCCCS ensures that premiums are not assessed on Native American or Alaska Native populations. • AHCCCS monitors the number of persons who are disenrolled due to nonpayment of premiums and notifies KidsCare members about their premium rights and responsibilities. • The first monthly premium is not required prior to initial enrollment in the program. • All premium payments are due by the 15th day of each month of enrollment.

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Approval Date: 48 • If the payment is not made by the due date, a past due notice will be sent with a request for payment no later than the last day of the month.

The premium amounts are:

PREMIUM AMOUNTS

Effective 2/1/04

Federal Poverty Levels (FPL) 1st Child More than 1 Child Above 100% to 150%

Above 150% - 175% $20.00 $30.00 Total Above 175% - 200% $25.00 $35.00 Total

Effective 7/1/04

Federal Poverty Levels (FPL) 1st Child More than 1 Child Above 100% to 150% $10.00 $15.00 Total Above 150% - 175% $20.00 $30.00 Total Above 175% - 200% $25.00 $35.00 Total

8.2.2. Deductibles: 8.2.3. Coinsurance or copayments: No copayments are charged. 8.2.4. Other:

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b))

Information about cost sharing is included in the following: • Education and application materials. • Member handbooks provided by KidsCare contractors. • Arizona Administrative Register and other rulemaking activities conducted by the AHCCCS Administration. • Native American newsletters and meetings make it clear that the Native American and Alaska Native populations are exempt from paying any cost sharing.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

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Approval Date: 49 8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f))

The state assures enrollees will not be held liable for cost-sharing amounts for emergency services that are provided at a facility that does not participate in the enrollee's managed care network.

8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family’s income for the length of the child’s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e))

Premiums will not exceed the five percent cumulative maximum. Families are advised on the notice of approval that the total cost sharing under KidsCare can not exceed five percent of the families’ income. Families are advised to contact AHCCCS if the total cost sharing exceeds the five percent limit. Upon notification, AHCCCS makes changes to the system to stop the imposition of monthly premiums.

8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

The Application for AHCCCS Health Insurance requests information about the child's race. If the child is American Indian or Alaska Native, AHCCCS does not assess a premium or copayment.

8.7. Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

A. The consequences for non payment of premium are as follows: 1. If the payment is not made by the due date, AHCCCS sends a past due notice with a request for payment no later than the last day of the month.

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Approval Date: 50 2. If the payment is not received by the 15th day of the second month, AHCCCS mails a ten-day discontinuance letter. Services are terminated if the delinquent payment is not received the end of the second month. If AHCCCS receives the delinquent payment prior to the end of the second month, there is no break in coverage. 3. Persons may be re-enrolled if all outstanding balances are paid and an updated application is submitted. B. The following is the hardship exemption to the disenrollment process: 1. The following definitions apply to this Section: a. "Major expense" means the expense is more than 10 percent of the household's countable income b. "Medically necessary" means as defined in 9 A.A.C. R9-22-101. 2. Whenever a monthly statement includes a past due amount and the benefits are at risk of being terminated, AHCCCS sends a separate notice with information about and instructions for requesting a hardship exemption. C. The Administration grants a hardship exemption to the disenrollment requirements under A.R.S. § 36-2982 for a household who:

1. Is no longer able to pay the premium due to one of the hardship criteria listed below, and 2. Requests and provides all necessary written verification at the time of request. D. The Administration considers the following hardship criteria: 1. Medically necessary expenses or health insurance premiums that: a. Are not covered under Medicaid or other insurance and b. Exceed 10 percent of the household's countable income; 2. Unanticipated major expense, related to the maintenance of shelter or transportation for work; 3. A combination of medically necessary and unanticipated major expenses in this section that exceed 10% of the household's countable income; or 4. Death of a household member. E. The Administration must receive the written request and verification of exemption eligible criteria by the 10th day of the month in which the household receives the billing statement containing the current and past due premium notice. F. The Administration notifies the head of household concerning the approval or denial of the request for exemption and discontinuance 10 days prior to the end of the month in which the request was received.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 51 disenrollment. (42CFR 457.570(a))

Medicaid rules regarding opportunities for impartial reviews prior to disenrollment apply to SCHIP. The premium payment is due by the 15th day of each month. If the payment is not made by the due date, AHCCCS sends a past due notice with a request for payment no later than the last day of the month. If the payment is not received by the 15th day of the second month, AHCCCS mails a ten-day discontinuance letter. Enrollees are ensured the opportunity to continue benefits pending the outcome of the hearing.

The disenrollment process affords the enrollee an opportunity to show that the enrollee’s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

KidsCare members may report a change at any time. If a change in income is reported, AHCCCS reevaluates KidsCare and Medicaid eligibility and the premium amount.

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child’s cost-sharing category as appropriate. (42CFR 457.570(b))

If a change in income results in a lower premium amount, AHCCCS adjusts the premium amount the next prospective month after the change is reported. If the child appears to be Medicaid eligible, AHCCCS refers the application and documentation to the Department of Economic Security for a Medicaid determination.

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

AHCCCS sends a notice to the household at least 10 days before benefits are discontinued due to non-payment. The notice includes information about the right to request a hearing and how to request a hearing. If AHCCCS receives the hearing request prior to the discontinuance effective date, AHCCCS may continue benefits pending the outcome of the hearing. Prior to the hearing date, AHCCCS discusses all information with the household to determine if the premium was calculated correctly. If the premium amount is correct, AHCCCS informs the household that the

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Approval Date: 52 premium amount is correct and that the household has the right to request a hearing. If the premium amount is not correct, AHCCCS corrects the premium amount and the hearing is not necessary.

8.8. The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e))

8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5) 8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475)

8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

Model Application Template for the State Children’s Health Insurance Program

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Approval Date: 53 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

Arizona has established the following strategic objectives for the KidsCare Program:

• Decrease the percentage of children in Arizona who are uninsured or who do not have a regular source of health care.

• Improve the health status of children enrolled in KidsCare in Arizona through a focus on early preventive and primary care.

• Ensure that KidsCare eligible children in Arizona have access to a regular source of care and ensure utilization of health care by enrolled children.

• Avoid “crowd out” of employer coverage.

• Coordinate with other health care programs providing services to children to ensure a seamless system of coverage.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

• Decrease the percentage of children in Arizona who are uninsured. (In the first year of the KidsCare Program, decrease the percentage of children with income under 150% of FPL who are uninsured and, in subsequent years, decrease the number of children with income under 200% of FPL who are uninsured.)

• Screen 100 percent of applications to determine if the child was covered by employer sponsored insurance within the last three months. If however, a child has exceeded the lifetime limit to his or her employer sponsored insurance policy; the child will not be required to go bare for three months.

• Improve the number of KidsCare eligible children who receive preventive and primary care by meeting goals according to Health People 2010:

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Approval Date: 54 1. 90 percent of children under two will receive age appropriate immunizations; 2. 90 percent of children under 15 months will receive the recommended number of well child visits; 3. 90 percent of three, four, five, and six year olds will have at least one well-child visit during the year; 4. 90 percent of children will have at least one dental visit during the year; and • Ensure that KidsCare enrolled children receive access to a regular source of care:

1. 100 percent of enrolled children will be assigned a PCP; and 2. 90 percent of KidsCare children will see a PCP at least once during the first 12 months of enrollment.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state’s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well childcare 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list: 9.3.8.

Performance measures for special targeted populations.

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Approval Date: 55 9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state’s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

AHCCCS will perform the annual assessments and evaluations required in Section 10. The annual report will include an assessment and update on the operation of the KidsCare Progam, including the increase in the percentage of Medicaid eligible children enrolled in Medicaid and the reduction in the percentage of uninsured children will be calculated from CPS data.

As addressed in Section 7, AHCCCS will measure the KidsCare Program’s progress toward meeting its strategic objectives and performance goals through an evaluation of the contractors using encounter data and medical chart audits, with particular emphasis on preventive and primary care measures.

In addition, annual Operational and Financial Reviews of the KidsCare contractors and reviews of the Quality Management Plans addressing quality standards and how contractors propose to meet those standards will assist AHCCCS in ensuring the quality of health coverage.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes)

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Approval Date: 56 9.8.4.

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

Arizona has developed a collaborative process with many interested parties in the design, implementation and evaluation of the KidsCare State Plan. The state has a process for conducting a statewide collaborative effort to provide the community with awareness, education and an opportunity to shape the KidsCare Program (see Attachment N). The Children’s Action Alliance also held public forums to discuss the parameters of the KidsCare Program.

In December 1997, the Governor convened a KidsCare Task Force consisting of state legislators, state agencies, representatives from the hospital and medical industry, advocacy organizations and tribal organization to develop recommendations about how targeted, low-income children could best be served by the funds available under Title XXI. The members of this task force are identified in Attachment O. The Governor’s Office also convened a special meeting for the 21 Arizona tribes to discuss tribal issues.

The Governor worked with key legislators and other interested parties to introduce legislation on KidsCare. This legislation and the public hearings provided significant opportunities for state legislators and the public to comment and participate in the development of the KidsCare Program. In these legislative hearings, there has been overwhelming support from the community as evidenced by the testimony in support of the program. In addition to the legislative hearings, the community has endorsed this KidsCare Program as shown in Attachment P.

AHCCCS convened two public hearings to discuss the proposed State Plan. Over 275 persons were sent a copy of the State Plan and invited to the hearings. Over 70 persons attended the hearings which included an overview of the State Plan and an open forum for comments, questions and answers. The majority of the discussion involved questions about the operation of the program or the potential for state legislative changes which were answered at the hearing. The suggestions for changes to the State Plan and comments from AHCCCS are summarized in Attachment Q.

As part of Senate Bill 1008, the legislature requires annual reports beginning January 1, 2000, containing the following information:

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Approval Date: 57 1. The number of children served by the program. 2. The state and federal expenditures for the program for the previous fiscal year. 3. A comparison of the expenditures for the previous fiscal year with the expected federal funding for the next fiscal year. 4. Whether the federal funding for the next fiscal years will be sufficient to provide services at the current percentage of the FPL or whether an enrollment cap may be needed. 5. Any recommendations for changes to the program will be submitted to the Governor, the President of the Senate, Speaker of the House of Representatives, Secretary of State, the Director of the Department of Library, Archives and Public Records so they can monitor the implementation and evaluation of the program.

As part of the public process, AHCCCS held two public hearings on the proposed State Plan to provide the public with an opportunity to comment and will also hold public hearings on all proposed rules for this program.

AHCCCS has included KidsCare as a regular agenda item for discussion with the State Medicaid Advisory Committee and is working closely with health plans who will be responsible for the delivery of services through the following forums:

• AHCCCS Health Plan meetings • Medical Directors’ meetings • Quality Management and Maternal Child Health meetings • Other types of meetings (e.g., one-on-one meetings, rule meetings and State Plan meetings). Please see sections 9.9.1 and 9.9.2 for a description of ongoing public involvement opportunities.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

AHCCCS has an ongoing communication with the tribal communities. (See section 2.2.1. and 4.4.5. and 8.3.) An article was written in the KidsCare News to communicate to the communities that no cost sharing is required. The Application for AHCCCS Health Insurance requests information about the child’s race. If the child is American Indian or Alaska Native, this information is input into the KEDS automated system which reads the race code and assigns a premium amount of zero.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 58 9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65(b) through (d).

The public has the ability to be involved through the legislative and/or rulemaking process. During the Legislative session, there are many opportunities that the public can make comment to the House of Representatives or Senate. (See section 9.9) AHCCCS ensures the public has the opportunity to be involved in the rulemaking process from the beginning to end. Initially, AHCCCS opens a docket and files a notice with the Secretary of State in the Arizona Administrative Register. Next, AHCCCS files proposed rules and notice with the Secretary of State in the Arizona Administrative Register. After that, AHCCCS receives written and oral comments from the public. The next step, involves a public hearing. The agency then reviews public comments and makes necessary changes to the proposed rules. In conclusion, the agency submits rules to the Governor's Regulatory Review Council for approval. The agency appears before the Council to answer questions regarding the rules. At this time, the public has one more opportunity to express their opinion (approval or disapproval) of the rule. After the Council approves the rules, the rule package is then filed with the Secretary of State.

Public notice for cost-sharing AHCCCS provided many avenues for public involvement in the Cost Sharing implementation.

The Office of Community Relations provided Community and Provider Forums in which participants and AHCCCS staff discussed the cost- sharing changes, as well as additional information on other AHCCCS program changes and future updates. These forums were held in: Flagstaff, Tucson, Phoenix (2), and Yuma from August 26, 2003 to September 23, 2003. 404 providers, 356 community members, advocates, interested individuals, etc attended the forums. The Arizona Republic published a two-paragraph description of the Forums under the Health Briefs. The Public Information Office had a brief description of the Forums in the Arizona Republic, which is Arizona's statewide newspaper.

The Office of Legal Assistance conducted Public Hearings in Phoenix, Tucson, and Flagstaff to reach individuals in the Northern, Central or Southern areas of Arizona. Information about date, time, and place of the

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 59 Public Hearings as well as the proposed rule language were posted September 4, 2003 on the AHCCCS website (www.ahcccs.state.az.us). AHCCCS accepted comments from the public on the rules from September 4, 2003 until close of business on September 24, 2003.

Seventeen individuals attended the public hearings held in Phoenix, Flagstaff, and Tucson. Prior to the hearings the agency received 7 written comments and, during the hearings, received public testimony from another 6 individuals. The majority of comments were from pharmacists or pharmaceutical companies concerned about the actual implementation of copays at the pharmacy counter. Comments were reviewed and merits discussed with executive management. On September 29, 2003 the final rules were filed with the Secretary of State's office and subsequently published in the Arizona Administrative Register on October 24, 2003. The following is a summary of the principle comments received at the public hearing and the agency’s response.

PRINCIPLE COMMENTS AHCCCS RESPONSE Does pharmacy co-pays suggest that consumers will have a choice between a branded or generic product? Almost all of the health plans that serve TXIX population have a mandatory generic policy in place, therefore branded products that have generic equivalents will generally reject at the pharmacy level with a message to use the generic product. Can you please clarify the proposed changes for prescription copayments.

The health plan practice regarding pharmacy management has not changed. A member is not allowed to pay the higher amount to have brand name medication. However, most health plans have brand name medication available as off formulary which would require prior authorization. R 9-22-711 E identifies the individuals who are subject to specific brand and generic co- payments and that the The implications for the pharmacy are the same as if any other person with another type of insurance would not have the

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 60 provider may deny a service if the member does not pay the required co-payment. What are the implications to the pharmacy if they deny service? money to pay the copay.

Federal Regulations prohibit pharmacies from collecting co-payments from Medicaid population when the individual refuses or is unable to pay the co-payment. Does A.R.S.36-2903.01 meet the federal standard? Has it been waived? If an individual refuses or is unable to pay the co-payment what actions may the pharmacy take regarding prescription services? Can they deny services Federal law prohibits services to be denied for the categorical "entitled" groups. However, services can be denied if copayments are not made by the non-categorical groups.

A Public Hearing was held in Phoenix on January 12, 2004 regarding the February 1, 2004 premium increase. No testimony was received either verbally or in writing.

One of the areas targeted by the Arizona legislature in various legislative hearings was an increase in the monthly premiums that would be paid by families who had children or adults enrolled in a SCHIP program. The February 2004 increase is the result of the legislative mandate to enhance cost sharing. Interested parties had an opportunity to testify in the several public hearings and during the public hearings on the changes to AHCCCS’ rules. In addition, the attached notice was sent to all who had children enrolled with KidsCare who would be affected by the increase in monthly premiums.

Public notice for the July 1, 2004 premium implementation for families with income between 100% and 150% of the FPL is scheduled for May 7, 2004. The Public Hearing will be held on June 9, 2004 to hear testimony on this premium change.

Prior Public Notice for Enrollment Freeze

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 61 Prior public notice of the enrollment cap will be communicated to the public by publication in the Arizona Administrative Register by the Secretary of State, posting on the AHCCCS Administration’s internet website, written communication to the Legislature and Governor, the State Medicaid Advisory Committee, and other interested stakeholders. Notice to the public was also provided on October 9, 2009, when AHCCCS posted information about the potential impact of implementing a 15% reduction which identified elimination of the KidsCare program as a discretionary program that would not jeopardize federal stimulus dollars or voter protected programs. Finally, a public hearing with the opportunity to present public comments will be held on December 29, 2009 and tribal consultation will be held on December 28, 2009.

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

• Planned use of funds, including -- - Projected amount to be spent on health services; - Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and - Assumptions on which the budget is based, including cost per child and expected enrollment. • Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

See Attachment S below for the KidsCare Budget. The state share of the program is funded with monies from the Tobacco Tax Fund.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 62 Attachment S

Title XXI Budget

FFY 2010 Enhanced FMAP rate 76.03% BENEFIT COSTS

Insurance payments

Managed Care and FFS $73,213,600 per member/per month rate X # of eligibles $166.35 Total Benefit Costs $73,213,600 (Offsetting beneficiary cost sharing payments) ($7,040,400) Net Benefit Costs $66,173,200

ADMINISTRATION COSTS

Personnel $6,003,300 General administration $1,349,300 Contractors/Brokers (e.g., enrollment contractors)

Claims Processing

Outreach/marketing costs

Other

Total Administration Costs $7,352,600 10% Administrative Cost Ceiling $7,352,600

Federal Share (multiplied by enhanced FMAP rate) $55,901,700 State Share $17,624,100 TOTAL PROGRAM COSTS $73,525,800

Notes:

1) Enrollment actuals through January 1, 2010.

2) Expenditure actuals through November 30, 2009.

3) Administrative Cost estimates are as of November 2009.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 63 Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.

The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2.

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3.

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 64 Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12.

11.1.

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

The award of contracts to managed care organizations, for delivery of health care services to KidsCare members, is done through a competitive bidding process. During the last bidding process in 1997, there was competition for the awards in every geographic service area (GSA) the area which is covered by each contract). Currently, in each GSA, the member may choose between at least two MCOs.

All capitation rates, paid to the MCOs for KidsCare members, have been certified as actuarially sound by the Agency’s consultant actuary firm.

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

Section 1128E (relating to the National health care fraud and abuse data collection program)

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 65 Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

12.1. Eligibility and Enrollment Matters

Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

AHCCCS provides the opportunity for an external review (a hearing) with an Administrative Law Judge who works for the Office of Administrative Hearings. The Office of Administrative Hearings is a separate State agency. The right to a hearing is explained on the agency’s decision notices which are sent to the primary informant when any action is taken to approve or deny eligibility, stop enrollment or increase the premium amount The notice provides an explanation of the hearing rights and gives the date by which a hearing must be requested, including the date to request a hearing if the person wants benefits to continue pending the hearing decision.

12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120.

The Administration provides both an informal and a formal review process to resolve health service matters presented by enrollees. The formal review process includes the opportunity for an expedited hearing which includes a formal evidentiary hearing. The hearing is conducted by an impartial third party, an Administrative Law Judge (ALJ), employed by an independent state agency, the Office of Administrative Hearings (OAH).

Enrollees are afforded due process. They may represent themselves or choose to be represented during the process. Additionally, they may fully participate in the process, having the opportunity to review all relevant information and to file supplemental information. If an expedited hearing is requested, it is held within 20-40 days of receipt of the request. State Law requires that the ALJ issue a recommended decision within 20 days from the date of the hearing, and that the Administration issue a decision adopting, modifying, or rejecting the ALJ recommended decision within 30 days. On average, this process is completed in less than 90 days.

If the dispute pertains to a reduction, suspension, or termination of services and

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 66 the enrollee files the request for expedited hearing within 15 business days of the postmark date of the notice, services will be continued until a final decision is rendered. State regulations and contract additionally authorize a hearing to be conducted on a more abbreviated timeframe if the enrollee establishes cause. Enrollees also have the option of challenging health services matters through an informal grievance process. Once a grievance determination is issued, the parties may request a formal evidentiary hearing which is conducted by OAH as generally outlined above

12.3. Premium Assistance Programs

If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

ARIZONA TITLE XXI PROGRAM FACT SHEET

1

Name of Plan:

KidsCare

Date Plan Submitted:

June 23, 1998 Date Plan Approved:

September 18, 1998 Date Plan Effective:

October 1, 1997

Date Amendment #1 Submitted: February 23, 1999 Date Amendment #1 Approved: May 21, 1999 Date Amendment #1 Effective: January 1, 1999

Date Amendment #2 Submitted: May 26, 1999 Date Amendment #2 Approved: August 23, 1999 Date Amendment #2 Effective: October 1, 1999

Date Amendment #3 Submitted: September 27, 1999 Date Amendment #3 Approved: December 1, 1999 Date Amendment #3 Effective: November 1, 1998

Date Amendment #4 Submitted: October 31, 2000 Date Amendment #4 Approved: January 26, 2001 Date Amendment #4 Effective: October 1, 2000

Date Amendment #5 Submitted: March 29, 2001 Date Amendment #5 Withdrawn: April 10, 2001

Date Amendment #6 Submitted: August 17, 2001 Date Amendment #6 Approved: November 15, 2001 Date Amendment #6 Effective: October 1, 2001

Date Amendment #7 Submitted: June 27, 2002 Date Amendment #7 Approved: September 19, 2002

Date Amendment #8 Submitted: September 22, 2003 Date Amendment #8 Approved: December 16, 2003 Date Amendment #8 Effective: October 1, 2003

Date Amendment #9 Submitted: January 14, 2004 Date Amendment #9 Approved: April 2, 2004 Date Amendment #9 Effective: February 1, 2004/July 1, 2004

Date Amendment #10 Submitted: April 29, 2004 Date Amendment #10 Approved: State withdrew on June 18, 2004

ARIZONA TITLE XXI PROGRAM FACT SHEET

2 Date Amendment #11 Submitted: February 11, 2009 Date Amendment #11 Approved: April 13, 2009 Date Amendment #11 Effective: May 1, 2009

Date Amendment #12 Submitted: December 31, 2009 Date Amendment #12 Approved: March 15, 2010 Date Amendment #12 Effective: January 01, 2010

Background

• On June 23, 1998, Arizona submitted a title XXI plan to extend health coverage through a separate child health program (KidsCare) to children in families with gross incomes up to 150 percent of the Federal poverty level (FPL) not otherwise eligible for Medicaid. As part of this plan, the income limit was to automatically increase to 175 percent of the FPL on July 1, 1999, then to 200 percent of the FPL on July 1, 2000.

• Under the State’s pre-existing Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS), children in families with the following income limits are covered: up to 140 percent of the FPL for children under age 1, up to 133 percent of the FPL for children ages 1 to 6, and up to 100 percent of the FPL for children age 6 or over born after September 30, 1983.

Amendments

• Arizona submitted its first amendment on February 23, 1999, to add circumstances in which a child would not be guaranteed an initial 12 months of continuous coverage.

• Arizona submitted its second amendment on May 26, 1999, to impose premiums on children in families with income above 150 percent of the FPL, effective October 1, 1999. The amendment also revised the phase-in of higher income limits to a single increase to 200 percent of the FPL effective October 1, 1999.

• Arizona submitted its third amendment on September 27, 1999, to target the reporting requirements regarding quality indicators, strategic objectives, and performance goals to the assurances and reports required by title XXI. On October 26, the State requested that two additions be made to this amendment: 1) a clarification that cost sharing of any kind will not be imposed on American Indians; and, 2) a request that children who have reached the lifetime limit on private insurance be considered uninsured for title XXI eligibility purposes.

• Arizona submitted its fourth amendment on October 31, 2000, to accept parental declaration of income for the KidsCare program.

• Arizona submitted its fifth amendment on March 29, 2001. It was withdrawn by the State on April 10, 2001.

ARIZONA TITLE XXI PROGRAM FACT SHEET

3

• Arizona submitted its sixth amendment on August 17, 2001, to reduce the required period of uninsurance from 6 months to 3 months, waive the period of uninsurance requirement for children who are seriously or chronically ill, and establish a process for a hardship exemption for disenrollment due to non-payment of premiums. The amendment also removes eyeglass limitations, adds non-emergency transportation, and removes the 30-day limitations on inpatient and outpatient behavioral health stays so that the benefit package is equal to the Medicaid package.

• Arizona submitted its seventh amendment on June 20, 2002. This amendment updated and amended the CHIP state plan to indicate the State's compliance with the final CHIP regulations.

• Arizona submitted its eighth amendment on September 22, 2003. This amendment increases monthly premiums for enrollees with incomes above 175 percent of the FPL and eliminates copayments for all enrollees.

• Arizona submitted its ninth amendment on January 14, 2004. This amendment increases monthly premiums for KidsCare enrollees with family incomes above 150 percent of the FPL, effective February 1, 2004. This amendment also imposes premiums on KidsCare enrollees with family incomes above 100 to 150 percent of the FPL, effective July 1, 2004.

• Arizona submitted its tenth amendment on April 29, 2004 to implement enrollment fees. It was withdrawn by the State on June 18, 2004.

• Arizona submitted its eleventh amendment on February 11, 2009. This amendment doubles monthly premiums for KidsCare enrollees with family income between 151 – 200 percent of the FPL, effective May 1, 2009.

• Arizona submitted its twelfth amendment on December 31, 2009. This amendment establishes policy for implementing an enrollment freeze for AZ KidsCare, effective January 01, 2010.

Children Covered Under Program

• The State reported that 105,140 children were ever enrolled in KidsCare during Federal fiscal year 2009.

Administration

• This program is administered by the State Medicaid agency.

ARIZONA TITLE XXI PROGRAM FACT SHEET

4 Health Care Delivery System

• Arizona provides KidsCare services through established AHCCCS health plans. American Indians may choose to receive services through the Indian Health Service (IHS), 638 tribal facilities, or one of the AHCCCS plans.

Benefit Package

• The benefit package is the Medicaid benefit package. If an American Indian selects the IHS or a tribal facility, AHCCCS provides any KidsCare services not provided by these entities on a fee for service basis off-reservation.

Cost Sharing

• The monthly premium amounts for families with income between 100 to 150 percent of the FPL are $10 for one child and $15 total for two or more children.

• The monthly premium amounts for families with income between 151 to 175 percent of the FPL are $40 for one child and $60 total for two or more children.

• The monthly premium amounts for families with income between 176 to 200 percent of the FPL are $50 for one child and $70 total for two or more children.

• There is a hardship exemption to the disenrollment process for non-payment of premiums. The hardship criteria include uncovered medically necessary expenses or insurance premiums for non-CHIP eligible household members that exceed 10 percent of the household’s countable income, unanticipated major expenses related to maintenance of shelter or transportation to work, and death of a household member.

Coordination between CHIP and Medicaid

• The State uses a joint application for KidsCare and Medicaid. Medicaid screening is part of the KidsCare eligibility determination process. Records of KidsCare eligibility are maintained in a database that is also used for Medicaid eligibility. Current Medicaid eligibility is checked before determining KidsCare eligibility. Medicaid eligibility always overrides KidsCare eligibility.

Crowd-Out Strategy

• Children must be without group health insurance for 3 months in order to be eligible for KidsCare. Eligibility workers will obtain a declaration as to whether the family member or employer has voluntarily discontinued employer-sponsored dependent insurance coverage in order to allow a child to participate in KidsCare. Exceptions to the 3-month period of uninsurance will be granted for newborns, for children who lost coverage due to

ARIZONA TITLE XXI PROGRAM FACT SHEET

5 a parent’s involuntary loss of employment, for children who have reached the lifetime limit on private insurance coverage, and for children who are seriously or chronically ill.

• AHCCCS monitors substitution under its Quality Control and Quality Assurance process to analyze the extent to which applicants drop other health coverage.

Outreach Activities

• Education regarding KidsCare is conducted through collaborative arrangements with other state, county and city agencies as well as programs that conduct education in rural and inner-city areas.

• Education efforts and the distribution of applications are targeted to those Agencies, organizations and other entities that currently serve targeted low-income children. Organizations distributing the applications and information about KidsCare are offered training to assist with completing the application form and collecting information. An applicant may also receive assistance to complete the application form by calling the AHCCCS 24-hour toll-free number.

Financial Information

FFY 2010 Allotment – $182,591,756 FFY 2010 Enhanced Federal Matching Rate – 76.03%

Last update: February 17, 2010

Table of Contents State/Territory Name: Arizona State Plan Amendment (SPA) #: 13-006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850 NTER FOR MEDICAID & Chip Senvic

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

OCT 23 2014

Ms. Melanie Norton, Assistant Director

Arizona Health Care Cost Containment System (AHCCCS) 801 E. Jefferson MD 2600

Phoenix, AZ 85034

Dear Ms. Norton:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number AZ-13-0006, submitted on June 19, 2014, with additional information provided on October 21, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number AZ-13-0006 describes the state’s plan to provide coverage in its separate CHIP, for children subject to Section 2101(f) of the Affordable Care Act, as specified in the state’ s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved CS14 is attached, and should be incorporated within a separate subsection under Section 4.1 of Arizona’s approved CHIP state plan.

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Ms. Hye Sun Lee, Acting Associate Regional Administrator (ARA) in our San Francisco Regional Office. Ms. Lee’s address is:

Page 2 — Ms. Melanie Norton

Centers for Medicare & Medicaid Services 90 7th Street, Suite 5-300 (SW) San Francisco, California 94103-6706

Congratulations on the approval. If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at (410) 786-0719.

We look forward to continuing to work with you and your staff.

Sincerely, Eliot Fishman Director Enclosure cc:

Ms. Hye Sun Lee, Acting ARA, CMS Region IX, San Francisco

cmMs. CHIP Eligibility

OMB Control Number: 0938-1148

Section 2101(f) of the ACA and 42 CFR 457.310(d)

[| Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

C The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to ~ Section 210 1(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

. The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their ’ first renewal apply ing MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who ’ would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP. :

(% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for

O Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applie d to the family income as determined by MAGI methodology.

(©) Other.

The state will identify children protected by Section 2101(f) and enroll such children in a separate CHIP based on the following methodology and procedures as approved by CMS.

In all cases where a child is found to be ineligible for Medicaid based on MAGI, the state will determine whether the child is protected by Section 2101(f). If so, the state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

Describe the benefits pro vided to this population:

OCT 2 3 2014

SPA# AZ-13-0006 Approval Date: Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

(This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

© Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C)Cost sharing is the same as for children in the Medicaid program.

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

(© Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

OCT 23 2014

SPA# AZ-13-0006 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Arizona State Plan Amendment (SPA) #: AZ-13-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Arizona consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services (CMs

7500 Security Boulevard, Mail Stop: S2-26-12 Cc M Ss CENTERS FOR MEDICARE & MEDICAID SERVICES

Baltimore, Maryland 21244-1850

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

OCT 2 3 2014

Ms. Melanie Norton, Assistant Director

Arizona Health Care Cost Containment System (AHCCCS) 801 E. Jefferson MD 2600

Phoenix, AZ 85034

Dear Ms. Norton:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number AZ-13-0006, submitted on June 19, 2014, with additional information provided on October 21, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number AZ-13-0006 describes the state’s plan to provide coverage in its separate CHIP, for children subject to Section 2101(f) of the Affordable Care Act, as specified in the state’ s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved CS14 is attached, and should be incorporated within a separate subsection under Section 4.1 of Arizona’s approved CHIP state plan.

Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning these amendments and other CHIP-related issues. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

Facsimile: (410) 786-5882

E-mail: Joyce.Jordan@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Ms. Hye Sun Lee, Acting Associate Regional Administrator (ARA) in our San Francisco Regional Office. Ms. Lee’s address is:

Page 2 — Ms. Melanie Norton

Centers for Medicare & Medicaid Services 90 7th Street, Suite 5-300 (SW) San Francisco, California 94103-6706

Congratulations on the approval. If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State Coverage Programs at (410) 786-0719.

We look forward to continuing to work with you and your staff.

Sincerely, Eliot Fishman Director Enclosure ce:

Ms. Hye Sun Lee, Acting ARA, CMS Region IX, San Francisco

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility AZ.1085.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Arizona State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. AZ-13-0006 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion  ish 2101(f) Gr Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page

Submitted By: Theresa Gonzales Last Revision Date: Sep 29, 2014 Submit Date: Jun 19, 2014 Character Count:99 out of 2000   Provides coverage for children ineligible for Medicaid due to the elimination of income disregards. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov

cmMs. CHIP Eligibility

OMB Control Number: 0938-1148

Section 2101(f) of the ACA and 42 CFR 457.310(d)

[| Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards The CHIP agency provides coverage for this group of children as follows:

C The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to ~ Section 210 1(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected

* from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

. The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their ’ first renewal apply ing MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who ’ would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP. :

(% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for

O Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applie d to the family income as determined by MAGI methodology.

(©) Other.

The state will identify children protected by Section 2101(f) and enroll such children in a separate CHIP based on the following methodology and procedures as approved by CMS.

In all cases where a child is found to be ineligible for Medicaid based on MAGI, the state will determine whether the child is protected by Section 2101(f). If so, the state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI who would have remained eligible for Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

Describe the benefits pro vided to this population:

OCT 2 3 2014

SPA# AZ-13-0006 Approval Date: Effective Date: January 1, 2014

Page | of 2

CHIP Eligibility

(This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

© Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C)Cost sharing is the same as for children in the Medicaid program.

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

(© Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

OCT 23 2014

SPA# AZ-13-0006 Approval Date: Effective Date: January 1, 2014 Page 2 of 2

_____________________________________________________________________________ Table of Contents State/Territory Name: Arizona State Plan Amendment (SPA) #: AZ-16-0017 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Arizona consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES ee

Centers for Medicare & Medicaid Services o 7500 Security Boulevard, Mail Stop $2-01-16 i“ C “Mi Ss Baltimore, MD 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

*

Monica H. Coury JUL 22 2016

Assistant Director

Arizona Health Care Cost Containment System Office of Intergovernmental Relations

801 East Jefferson

Phoenix, AZ 85034

Dear Ms. Coury:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your title XXI Children’s Health Insurance Program (CHIP) state plan amendments (SPAs) AZ-16-0016 and AZ-16-0017.

Arizona’s SPA AZ-16-0016, submitted on May 23, 2016 and effective on July 26, 2016, lifts the state’s existing enrollment freeze enabling children ages birth through age 19 with income above 133 percent up to and including 200 percent of the federal poverty level (FPL) to enroll in the state’s CHIP, known as “KidsCare.” The state’s enrollment into its separate CHIP was initially frozen on January 1, 2010. While enrollment was temporarily opened as part of a section 1115 demonstration, KidsCare II, from May 2012 to January 2014, KidsCare II was sunset on January 31, 2014. With this SPA, we support the state’s efforts to ensure that low income uninsured children have access to affordable coverage and the protections that exist under CHIP.

CMS is also approving SPA AZ-16-0017, which was submitted on May 27, 2016 and has an effective date of July 26, 2016. This SPA reduces the state’s existing premium lock-out period from 90 to 60 days. Consistent with 42 CFR 457.570, states may identify a state-specified period of time (referred to as a premium lock-out period) that a CHIP eligible child who has an unpaid premium may not reenroll in coverage in CHIP.

Your title XXI project officer is Ms. Tonia Brown. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Brown’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-8613

Facsimile: (410) 786-5943

E-mail: Tonia.Brown@cms.hhs.gov

Page 2 — Ms. Monica H. Coury

Official communications regarding program matters should be sent simultaneously to Ms. Brown and to Ms. Kristin Dillon, Associate Regional Administrator (ARA) in our San Francisco Regional Office. Ms., Dillon’s address is:

Centers for Medicare & Medicaid Services 90 7th Street, Suite 5-300 (W) San Francisco, California 94103-6706

If you have additional questions, please contact Mr. Manning Pellanda, Director, Division of State Coverage Programs, at (410) 786-5143. We look forward to continuing to work with you and your staff.

Sincerely,

Anne Marie Costel! Director

Enclosures cc: Ms. Kristin Dillon, ARA, CMS Region IX, San Francisco

Control Panel

General Information

File Management Tribal Input

Summary

Children's Health Insurance Program Eligibility

Children's Health Insurance Program Eligibility: Summary Page

State/Territory Arizona

name: Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- Y¥-0000 where ST= the state abbreviation, YY = the Jast two digits of the submission year, and 0000 = a four digit number

with leading zeros. The dashes must also be entered. |Az-16-0017

Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing “ Non-Financial Eligibility

Proposed Effective Date

(nm/dc/ yyy)

Federal Statute/ Regulation Citation

|42 CFR 457.570

Federal Budget Impact

This SPA has a budget impact. Total budget impact:

State Funds: $ Federal Funds: $

Subject of Amendment

Please provide a brief summary of SPA changes. Character Count:148 out of 2000 Indates the CHIP State Plan Form C3521 re Non-Financial

ligibility-— Non-Payment of Premiums to change the lock-out eriod from 90 days to two months

Signature of State Agency Official

Submitted By: Theresa Gonzales

Last Revision May 31, 2016 Date: Submit Date: May 27, 2016

BACK _ CONTINUE)

CHIP Eligibility

State Name:[Arizona ¥ | OMB Control Number: 0938-1148 Transmittal Number: AZ - 16 - 00{7

Expiration date: 10/31/2014

42 CFR 457.570

Non-Payment of Premiums

Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

The State imposes a lock-out period consistent with the time periods in federal regulation.

What is the length of the time premium lock-out period? Select a length of time: © One month

@ Two months © 90 days

© Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? No

The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20140415

SPA# AZ-16-0017 Approval Date: JUL 2 2 2016

Effective Date: July 26, 2016 Page | of |

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 32-01-16 Baltimore, MD 21244-1850 Children and Adults Health crvrs cÉNüRS tOR M¡OIC^ßE & MtDtC to Sftvlcts CENTTT FON ilED¡CAID & CHIP SCNYICES Group FËB I b 2018 Tom Betlach State Medicaid Director Arizona Health Care Cost Containment System 801 E. Jefferson St. Phoenix, AZ 85034 Dear Mr. Betlach: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA) AZ-17-0010 has been approved. AZ-17-0010 implements mental health parity requirements in section 2103(c)(6) of the Social Security Act (the Act) and regulations at 42 CFR 451.496 to ensure that treatment limitations and financial requirements applied to mental health and substance use disorder benefits are no more restrictive than those applied to medical/surgical benefits. This SPA has an effective date of October I ,2017. Section 2103(cX6)(B) of the Act, as implemented through regulations at 42 CFR 457.496(b), provides that if CHIP coverage includes the Early, Periodic Screening, Diagnostic and Treatment (EPSDT) benefit as defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the state plan will be deemed to satisfy parity requirements. Arizona has provided the necessary assurances and supporting documentation that EPSDT is covered under Arizona's CHIP program and provided in accordance with sections 1905(r) and 1902({@3) of the Act. This approval relates only to benefits provided under the CHIP state plan; Medicaid benefits will be analyzed separately. Your title XXI project officer is Jasmine Aplin. She is available to answer questions concerning these amendments. Ms. Aplin's contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1 850 Telephone: (410) 786-8102 E-mail: jasrnine.aplin@crns.hhs. gov

official communications regarding program matters should be sent simultaneously to Ms. Jasmine Aplin and to Ms. Henrietta sam-Louie, Associate Regional Administrator in our san Francisco Regional OfÏice. Ms. Sam-Louie's address is: Centers for Medicare & Medicaid Services Division of Medicaid and Children's Health Operations 90-7th Street, Suite 5-300 San Francisco, CA 94103 Ifyou have additional questions or concerns, please contact Ms. Amy Lutzky, Director, Division of state coverage Programs, at (4r0) 786-0721. we look forward to continuing to woik with you and your staff. úØ Page 2 - Mr. Tom Betlach Ma¡ie Costello Director Enclosures cc: Ms. Henrietta Sam-Louie, ARA, CMS Region IV, San Francisco / Anne Marie Costello /

_____________________________________________________________________________ Table of Contents State/Territory Name: Arizona State Plan Amendment (SPA) #: AZ-17-0010 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Pages The complete title XXI state plan for Arizona consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following pages are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these pages fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

Original Implementation date:

November 1, 1998

Amendment Effective date:

February 1, 2004 (premiums >150% FPL)

July 1, 2004 (premiums 100%-150% FPL)

May 1, 2009 (premiums >150% FPL)

January 1, 2010 (enrollment cap)

October 10, 2013 (remove wait list)

July 26, 2016 (remove enrollment cap)

August 6, 2016 (premium lock out period)

October 1 2017 (mental health parity)

1.4-TC Tribal Consultation (Section 2107 (e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred, and who was involved.

The State of Arizona seeks advice on a regular, ongoing basis from all of the federally-recognized tribes, Indian Health Service (IHS) Area Offices, tribal health programs operated under P.L. 93- 638, and urban Indian health programs in Arizona regarding Medicaid and CHIP matters. These matters include but are not limited to State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals, and proposals for demonstration projects. The AHCCCS Tribal Consultation Policy serves as a guidance document that includes the process by which reasonable notice and opportunity for consultation should occur and scenarios in which AHCCCS shall engage in the consultative process.

The frequency of consultation is dependent on the frequency in which policy changes are proposed. When a proposed policy change requires consultation, the State will to its best ability provide notice of the tribal consultation meeting date as well as a description of the proposed policy change to be discussed. Ideally, a consultation meeting, which provides an opportunity for discussion and verbal comments to be made regarding a proposed change, will occur either in-person or by conference call 45 days prior to the submission of the policy change to CMS. The State will also provide an opportunity for written comments. Ideally, during the 45-day period, tribes and I/T/U will be provided at least 30 days to submit written comments regarding the policy change for consideration. Verbal comments presented at the meeting as well as written comments will be included in an attachment to accompany the submission of a State Plan Amendment, waiver proposal, waiver renewal, or proposal for a demonstration project.

Effective Date:07-26-1610/-1-17 3

Approval Date: 7-22-16

Effective Date: 10-01-17 7 Approval Date:

Section 6 Coverage Requirements for Children’s Health Insurance

Effective Date: 10-01-17 Approval Date: Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

 Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.)

6.1.1  Benchmark coverage; (Section 2103(a)(1))

6.1.1.1.  FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.)

6.1.1.2.  State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.1.3.  HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.  Benchmark-equivalent coverage; (Section 2103(a)(2)) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach signed actuarial report that meets the requirements specified in Section 2103(c)(4). See instructions.

6.1.3.  Existing Comprehensive State-Based Coverage; (Section 2103(a)(3)) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If “existing comprehensive state-based coverage” is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for “existing comprehensive state-based coverage.”

6.1.4  Secretary-Approved Coverage. (Section 2103(a)(4))

Arizona will use the same benefits as are provided under the Medicaid State plan. Any limitations on the covered services are discussed in this section and will be delineated in the AHCCCS Medical Policy Manual. The cost sharing requirements are specified in Section 8 of the State Plan.

Members who enroll in the KidsCare Program who select an AHCCCS health plan or the state employee HMO, if the HMO

Effective Date: 10-01-17 Approval Date: elects to participate in the program, will receive the following KidsCare services, subject to the limitations described below: 6.1.4.1. X Coverage of all benefits that are provided to children that is the same as the benefits provided under the Medicaid State plan, including Early Periodic Screening, Diagnostic, and Treatment (EPSDT).

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage.

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state-based coverage applicable only in New York, Pennsylvania or Florida. (under 42 CFR 457.440)

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done).

6.1.4.7.

Other. (Describe)

The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a))

6.2.1.  Inpatient services (Section 2110(a)(1))

a. Inpatient hospital services, including medically necessary ancillary services, and emergency hospital services, if furnished by a licensed hospital and provided by or under the direction of a PCP or primary care practitioner according to federal and state law, rules, and AHCCCS Policies and Procedures. Inpatient hospital services include services provided in an institution specializing in the care and treatment of members with mental diseases. b. Services in an Institution for Mental Diseases (IMD) when the member requires services in an inpatient psychiatric hospital. IMD are available to members who are determined to require these services after enrollment in KidsCare. However, applicants in an IMD at the time of application are excluded from enrollment in KidsCare. c. Medically necessary transplant services, which are not experimental, if provided to correct or ameliorate disabilities,

Effective Date: 10-01-17 Approval Date: physical illnesses or conditions. Transplantation services will be authorized in accordance with AHCCCS transplantation policies.

6.2.2.  Outpatient services (Section 2110(a)(2))

Outpatient hospital services ordinarily provided in hospitals, clinics, offices and other health care facilities by licensed health care providers. Outpatient hospital services include services provided by or under the direction of a PCP or primary care practitioner or licensed or certified behavioral health professional according to federal and state law. Certified behavioral health professionals include certified independent social workers, certified marriage/family therapists, and certified professional counselors.

6.2.3.  Physician services (Section 2110(a)(3))

Physician services if provided by or under the direction of a PCP, psychiatrist, or under the direction of a primary care practitioner according to federal and state law. Services are covered whether furnished in the office, the member’s home, a hospital, a nursing home or other setting.

Only psychiatrists, psychologists, certified psychiatric nurse practitioners, physician assistants, certified independent social workers, certified marriage/family therapists, and certified professional counselors may bill independently for behavioral health services. Other behavioral health professionals, behavioral health technicians and behavioral health paraprofessionals shall be affiliated with, an AHCCCS registered behavioral health agency and services shall be billed through that agency.

6.2.4.  Surgical services (Section 2110(a)(4))

Medically necessary surgical services under inpatient and outpatient services (Sections 6.2.1 and 6.2.2).

6.2.5.  Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

a. Outpatient services (Section 6.2.2). b. Ambulatory services offered by a health center receiving funds under section 330 of the Public Health Services Act. c. Rural health clinic services and federally qualified health center services and other ambulatory services.

6.2.6.  Prescription drugs (Section 2110(a)(6))

Effective Date: 10-01-17 Approval Date: a. Pharmaceutical services provided to a member if prescribed by the attending physician, practitioner, or dentist. b. Prescription drugs for covered transplantation services provided according to AHCCCS transplantation policies. c. Generally, medications dispensed by a physician or dentist are not covered.

6.2.7.  Over-the-counter medications (Section 2110(a)(7))

6.2.8.  Laboratory and radiological services (Section 2110(a)(8))

Laboratory, radiological and medical imaging services.

6.2.9.  Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9))

a. The following family planning services: • Contraceptive counseling, medication, supplies and associated medical and laboratory exams • Natural family planning education or referral b. Infertility services and reversal of surgically induced infertility are not covered services. c. Family planning services do not include abortion or abortion counseling.

6.2.10.  Inpatient mental health services, other than services described in 6.2.18, but including services furnished in a state-operated Medicare certified mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10))

a. Inpatient behavioral health services, other than inpatient and residential substance abuse treatment services, but including services furnished in a state operated mental hospital and including residential or other 24-hour therapeutically planned structured services. b. Services in a state operated mental hospital (e.g., Institution for Mental Diseases). IMD services are only available to members who are determined to require these services after enrollment. Applicants who are receiving IMD services at the time of application are excluded from enrollment in KidsCare.

c. Partial care services are included as part of the inpatient

benefit.

6.2.11.  Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-

Effective Date: 10-01-17 Approval Date: operated mental hospital and including community-based services (Section 2110(a)(11)

a. Outpatient behavioral health services, other than substance abuse treatment services, including services furnished in a state operated mental hospital (e.g., IMD) and community-based services. b. Outpatient behavioral health services includes individual and/or group counseling/therapy, rehabilitation services, including basic and intensive partial care, emergency/crisis services, behavior management, psychosocial rehabilitation, evaluation and behavioral health related services. 6.2.12.  Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

Formatted: Indent: Left: 0", First line: 0"

Effective Date: 10-01-17 Approval Date:

See Section 6.2.17--Dental services for coverage of dental devices. Vision services include prescriptive lenses.

6.2.13. X Disposable medical supplies (Section 2110(a)(13))

Medical supplies include consumable items that are disposable and are essential for the member’s health.

6.2.14. Home and community-based health care services (See instructions) (Section 2110(a)(14))

6.2.15. X Nursing care services (See instructions) (Section 2110(a)(15)) a. Private duty nursing care, respiratory care services, and services provided by certified nurse practitioners in a home or other setting. b. Certified nurse midwife services when they are rendered in collaboration with a licensed physician or PCP or primary care practitioner in accordance with AHCCCS Policies and Procedures.

6.2.16. X Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

A physician shall provide written certification of necessity of abortion.

6.2.17. X Dental services (Section 2110(a)(17)) a. Dental services, including routine, preventive, therapeutic and emergency services.

b. Dentures and dental devices are covered if authorized in consultation with a dentist. 6.2.18. X Vision screenings and services (Section 2110(a)(24))

6.2.19. X Hearing screenings and services (Section 2110(a)(24)) 6.2.1820. X Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) Inpatient substance abuse treatment is limited to acute detoxification.

6.2.1921. X Outpatient substance abuse treatment services (Section 2110(a)(19)) a. Refer to coverage under 6.2.11 - Outpatient mental health services, subject to the limitations prescribed in that section. b. Rehabilitation services provided by a substance abuse rehabilitation agency that do not exceed 30 outpatient visits for each 12-month period of eligibility.

Effective Date: 10-01-17 Approval Date:

6.2.220. X Case management services (Section 2110(a)(20))

Case management for persons with developmental disabilities.

6.2.231. X Care coordination services (Section 2110(a)(21)) Care coordination are available through contractors, primary care providers and behavioral health providers.

6.2.242. X Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

Therapy services are covered when necessary to prevent or ameliorate a condition, illness or injury, to prevent or correct abnormalities detected by screening or diagnostic procedures or to maintain a level of ability.

6.2.253. X Hospice care (Section 2110(a)(23))

Hospice services for a terminally ill member. 6.2.26. X EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

6.2.274. X Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) a. Services provided in a facility, home, or other setting if recognized by state law. b. Respiratory therapy. c. Eye examinations for prescriptive lenses. d. Immunizations, preventive health services, patient education, age and gender appropriate clinical screening test and periodic health exams.

6.2.285 Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.296. X Medical transportation (Section 2110(a)(26))

Emergency ambulance and non-emergency transportation are covered services when the transportation is medically necessary.

6.2.3027. X Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27))

All printed materials are in English and Spanish. Outreach services will be available through AHCCCS, and others as specified in Section 4.4.5 and Section 5.

Effective Date: 10-01-17 Approval Date: 6.2.3128.X Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28)) 1. Nursing facility services in a nursing facility or in an alternative residential setting for a maximum of 90 days when the medical condition of the person indicates that these services are necessary to prevent hospitalization. 2. Total parenteral nutrition services. 3. Podiatry services and optometrist services if furnished by a licensed podiatrist or optometrist, respectively. 4. Other practitioner’s services are covered and include services provided by: a. Respiratory Therapists b. Certified Nurse Practitioners c. Certified Nurse Anesthetists d. Physician Assistants e. Nonphysician behavioral health professionals if the services are provided by social workers, physician assistants, psychologists, counselors, registered nurses, certified nurse practitioners, behavioral health technicians and other approved therapists who meet all applicable state standards. Except for behavioral health services provided by psychologists, psychiatric nurse practitioners, physician assistants, certified independent social workers, certified marriage/family therapists, and certified professional counselors, all nonphysician behavioral health professional services shall be provided by professionals affiliated with an approved behavioral health setting in accordance with rules and AHCCCS policies and procedures. 5. Home health services a. Home health services when necessary to prevent re- hospitalization or institutionalization, and may include home health nursing services, therapies, personal care, medical supplies, equipment and appliances and home health aide services. b. Nursing service and home health aide if provided on an intermittent or part time basis by a home health agency. When no home health agency exists, nursing services may be provided by a registered nurse. c. Therapy services. Covered services are required to be authorized by the appropriate entity, unless otherwise indicated. Authorization by an appropriate entity shall be performed by at least one of the following: a PCP, primary care practitioner, or behavioral health professional as required by rule and AHCCCS policies and procedures. The appropriate entity shall authorize medically necessary services in

Effective Date: 10-01-17 Approval Date: compliance with applicable federal and state laws and regulations, AHCCCS policies and procedures and other applicable guidelines.

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: ) Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan.

Effective Date: 10-01-17 Approval Date: A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

Effective Date: 10-01-1701

Approval Date:

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A)) 6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1. X The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2. The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

Effective Date: 10-01-1701

Approval Date:

Effective May 1, 2009, the premium amounts for children when parents are not enrolled are as follows: PREMIUM AMOUNTS

Federal Poverty Levels (FPL) 1st Child More than 1 Child 100% to 150% $10.00 $15.00 151% - 175% $40.00 $60.00 Total 176% - 200% $50.00 $70.00 Total

8.2.2. Deductibles: Not Applicable

8.2.3. Coinsurance or copayments: No copayments are charged.

8.2.4. Other: N/A

8.3. Describe how the public will be notified, including the public schedule, of this cost-sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b)) Information about cost sharing is included in the following: • Member notices will be sent prior to implementation • Education and application materials. • Member handbooks provided by KidsCare contractors. • Arizona Administrative Register and other rulemaking activities conducted by the AHCCCS Administration. • Native American newsletters and meetings make it clear that the Native American and Alaska Native populations are exempt from paying any cost sharing. • Posted on the AHCCCS public website • Presented to the State Medicaid Advisory Committee

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e))

8.4.1. X Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530) 8.4.2. X No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3 X No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f)) The state assures enrollees will not be held liable for cost-sharing amounts for emergency services that are provided at a facility that does not participate in the enrollee's managed care network.

Effective Date: 10-01-1701

Approval Date:

8.4.1- MHPAEA There is no separate accumulation of cumulative financial requirements, as defined in 42 CFR 457.496(a), for mental health and substance abuse disorder benefits compared to medical/surgical benefits. (42 CFR 457.496(d)(3)(iii))

8.4.2- MHPAEA If applicable, any different levels of financial requirements that are applied to different tiers of prescription drugs are determined based on reasonable factors, regardless of whether a drug is generally prescribed for medical/surgical benefits or mental health/substance use disorder benefits. (42 CFR 457.496(d)(3)(ii)(A))

8.4.3- MHPAEA Cost sharing applied to benefits provided under the State child health plan will remain capped at five percent of the beneficiary’s income as required by 42 CFR 457.560 (42 CFR 457.496(d)(3)(i)(D)).

8.4.4- MHPAEA Does the State apply financial requirements to any mental health or substance use disorder benefits? If yes, specify the classification(s) of benefits in which the State applies financial requirements on any mental health or substance use disorder benefits.

Yes (Specify: ) No

_____________________________________________________________________________ Table of Contents State/Territory Name: Arizona State Plan Amendments (SPA) #: AZ-19-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Seruices 7500 Security Boulevard, Mail Stop 32-0'1.-16 Baltirnore, MD 2:l2M-1850 ctvts cEN¡tßs FCtn MÉDtcÀtt & MEDtCAtD StnV|C[S CENIER FON MEDICAID & CllIP SERYICES Children and Adults Health Prosrams Grouo AUG I 5 20t9 Jami Snyder Director Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034 Dear Ms. Snyder: I am pleased to inform you that your title XXI Children's Health Insurance Program (CHIP) state plan amendment (SPA), AZ-19-0003, has been approved. A2-19-0003 demonstrates compliance with the CHIP managed care regulations at 42 CFR 457, Subpart L, for utilization of a managed care delivery system. This SPA has an effective date of July 1,2018. Sections 2l0l(a),2103(Ð(3), 2107(b), and2107(e) of the Social Security Act, as implemented through regulations at 42 CFR 457 Subpart L, describe the application of managed care requirements to CHIP. Arizona has provided the necessary assurances indicating that the state complies with the managed care requirements in the delivery of CHIP services and benefits covered under the state's separate child health plan as of July l, 201 8. This SPA approval does not substitute for CMS review of any contracts between the state and managed care entities that serve the state's CHIP populations. All managed care contracts for CHIP populations in effect as of the state fiscal year beginning on or after July 1, 201 8 must comply with the CHIP managed care regulations and be submitted for CMS review. Your title XXI project officer is Ms. Joyce Jordan. She is available to answer questions concerning this amendment and other CHlP-related issues. Ms. Jordan's contact information is as follows: Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1 850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov

Page 2 - Ms. Jami Snyder Official communications regarding program matters should be sent simultaneously to Ms. Jordan and to Mr. Richard Allen, Director, Division of Medicaid Field Operations West. Mr. Allen's address is: Centers for Medicare & Medicaid Services 1961 Stout Street Room 08-148 Denver, Colorado 80294 If you have additional questions, please contact Amy Lutzky, Director, Division of State Coverage Programs at ( 410) 786-0721. We look forward to continuing to work with you and your staff. cc: Sincerely, ({jJ ) Ct::m0c D Anne M Costello Director Mr. Richard Allen, Director, Division of Medicaid Field Operations West /signed Anne Marie Costello/

Original Implementation date: November 1, 1998 Amendment Effective date: February 1, 2004 (premiums >150% FPL) July 1, 2004 (premiums 100%-150% FPL) May 1, 2009 (premiums >150% FPL) January 1, 2010 (enrollment cap) October 10, 2013 (remove wait list) July 26, 2016 (remove enrollment cap) August 6, 2016 (premium lock out period) October 1, 2017 (mental health parity) July 1, 2018 (Managed Care Regulations) 1.4-TC Tribal Consultation (Section 2107 (e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred, and who was involved. The State of Arizona seeks advice on a regular, ongoing basis from all of the federally-recognized tribes, Indian Health Service (IHS) Area Offices, tribal health programs operated under P.L. 93- 638, and urban Indian health programs in Arizona regarding Medicaid and CHIP matters. These matters include but are not limited to State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals, and proposals for demonstration projects. The AHCCCS Tribal Consultation Policy serves as a guidance document that includes the process by which reasonable notice and opportunity for consultation should occur and scenarios in which AHCCCS shall engage in the consultative process. The frequency of consultation is dependent on the frequency in which policy changes are proposed. When a proposed policy change requires consultation, the State will to its best ability provide notice of the tribal consultation meeting date as well as a description of the proposed policy change to be discussed. Ideally, a consultation meeting, which provides an opportunity for discussion and verbal comments to be made regarding a proposed change, will occur either in-person or by conference call 45 days prior to the submission of the policy change to CMS. The State will also provide an opportunity for written comments. Ideally, during the 45-day period, tribes and I/T/U will be provided at least 30 days to submit written comments regarding the policy change for consideration. Verbal comments presented at the meeting as well as written comments will be included in an attachment to accompany the submission of a State Plan Amendment, waiver proposal, waiver renewal, or proposal for a demonstration project. Effective Date: 7-1-1810-1-17 3 Approval Date:

Section 3 MMethods of Delivery and Utilization Controls

1

Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4)) Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 4. 3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a)) AHCCCS administers the Title XXI KidsCare Program. The program uses Title XXI funding to provide targeted, low income children with a choice of one of the 10 prepaid, capitated AHCCCS health plans, the Indian Health Service and P.L. 638 tribal facilities. AHCCCS HEALTH PLANS In partnership with AHCCCS, the health plans have been delivering quality, managed care services for almost 20 years. Their commitment to quality management is evidenced by the fact that at least half of the contractors voluntarily have sought and received accreditation from the National Committee for Quality Assurance (NCQA). Please see Attachment E for a profile of the current health plans who participate in the KidsCare Program. AHCCCS health plans have been very successful in assuring access to care. Over 89 percent of practicing physicians in the state participate in the program. Care is available in a wide range of settings, including FQHCs and many of the Rural Health Centers, who have elected to subcontract with the health plans. AHCCCS health plans are held to the same standards for KidsCare that are required for the Medicaid program. In order to secure a contract to deliver Medicaid services, bidders must respond to a Request for Proposal (RFP) and submit a proposal with specific capitation rates for one or more of the nine geographic service areas in the state. A critical element in the bid evaluation performed by AHCCCS is an assessment of how each prospective contractor will meet all financial and operational requirements, ensure quality of care and provide a sufficient network to meet specified accessibility requirements. Following is a more detailed description of the elements which are scored during the RFP process: Program Member Services Quality and Utilization Management Early Periodic Screening Diagnosis and Treatment Maternal Health/Women’s Health Behavioral Health Services

2

Provider Network Development of Capacity Management and Oversight

Organization Organization and Staffing Fraud and Abuse Subcontracts Claims and Third Party Liability Liability Management Grievance and Appeals Financial Standards Encounters

Capitation Rates All offerors submit detailed capitation bids which are evaluated against actuarially sound rate ranges. For the KidsCare Program, AHCCCS sets the rates based on an actuarial analysis.

Ongoing Monitoring

AHCCCS monitors the solvency of the health plans and their delivery of health care services with the following activities:

Quarterly and annual financial reporting On-site annual operational and financial reviews Performance measures using administrative data and medical records Member surveys Network reporting Encounter validation studies to determine completeness, accuracy and timeliness Solvency standards Coordination of benefits Educational efforts Medical studies Frequent meetings with contractors’ executive management

Other Intergovernmental Agreements

In addition to amending health plan contracts, AHCCCS has amended the the current Intergovernmental Agreements with the ADHS for behavioral health services and children’s rehabilitative services, and the DES for KidsCare services provided to foster care children. Amendments with ADHS are necessary to provide behavioral health services through the Regional Behavioral Health Authorities for the KidsCare population and to reimburse ADHS for services provided to KidsCare eligible special needs children who are also enrolled in the CRS program. The amendment with DES is

3

necessary to direct foster children eligible for KidsCare to the Comprehensive Medical and Dental Program, which is the current health plan for foster care children.

Indian Health Services/638 Tribal Facilities

AHCCCS also enables KidsCare eligible Native American children to use the Indian Health Service or 638 facilities operated by tribal governments who want to participate in the program. Of course, a Native American child who is eligible for KidsCare may also elect to enroll with one of the available AHCCCS health plans or a participating state employee HMO.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b)) AHCCCS has a managed care system that relies on multiple strategies to provide appropriate and medically necessary services. Children enrolled in the KidsCare Program have a choice to enroll with any of the available contractors in their geographic service area, including Indian Health Services, and have the right to choose a primary care provider (PCP) from the available practitioners. The PCP is contractually responsible for coordinating the care of members and approving referrals for medically necessary specialty services.

The AHCCCS Medical Policy Manual (AM/PM), which is available to all contractors and providers, specifies covered and excluded services under the KidsCare Program, as well as prior authorization (PA) requirements.

Each contractor is responsible for maintaining a utilization management program which includes: medical claims review, concurrent review, inpatient discharge planning, profiles of individual providers, drug utilization monitoring, analysis of durable medical equipment orders and non-emergency prior authorization.

Contractors must have a 24-hour telephone number staffed by health care professionals who advise members about the appropriate use of the emergency room and how to use urgent care centers. KidsCare members are subject to a $5.00 copayment when Emergency Departments are utilized for nonemergency services, in order to discourage inappropriate use of these facilities.

AHCCCS reviews and monitors contractors’ utilization management through an analysis of their financial reporting, through on-site operational and financial reviews and reviews of the utilization reports and the annual utilization management plan submitted by the contractors. These tools are discussed further in Section 7.1.

Effective Date: 7-1-18 Approval Date: 4

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4 (Eligibility Standards and Methodology).

3.1. Delivery Systems (Section 2102(a)(4)) (42 CFR 457.490; Part 457, Subpart L)

3.1.1 Choice of Delivery System 3.1.1.1 Does the State use a managed care delivery system for its CHIP populations? Managed care entities include MCOs, PIHPs, PAHPs, PCCM entities and PCCMs as defined in 42 CFR 457.10. Please check the box and answer the questions below that apply to your State. No, the State does not use a managed care delivery system for any CHIP populations. Yes, the State uses a managed care delivery system for all CHIP populations. Yes, the State uses a managed care delivery system; however, only some of the CHIP population is included in the managed care delivery system and some of the CHIP population is included in a fee-for-service system. If the State uses a managed care delivery system for only some of its CHIP populations and a fee-for-service system for some of its CHIP populations, please describe which populations are, and which are not, included in the State’s managed care delivery system for CHIP. States will be asked to specify which managed care entities are used by the State in its managed care delivery system below in Section 3.1.2. All CHIP eligible children – other than American Indians – are required to receive services through a managed care delivery system; American Indian children can elect to receive services through managed care or on a a FFS basis which is referred to as the American Indian Health Plan (AIHP). Additionally, American Indian children can receive services from I.H.S. and 638 facilities regardless of managed care enrollment.

If the State does not use a managed care delivery system for any or some of its CHIP populations, describe the methods of delivery of the child health assistance using Title XXI funds to targeted low- income children. Include a description of:

Effective Date: 7-1-18 Approval Date: 5 • The methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102(a)(4); 42 CFR 457.490(a)) • The utilization control systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102(a)(4); 42 CFR 457.490(b)) AHCCCS enables KidsCare eligible members to access services covered under one of the available Health Plans. Previously enrolled members who have been disenrolled for less than 90 days will be automatically enrolled with the same Contractor, if still available, pursuant to the terms of the Arizona Medicaid Section 1115 Demonstration Waiver Special Terms and Conditions [42 CFR 438.56(g)]. AHCCCS members eligible under a contracted Health Plan who become eligible for another AHCCCS Program will be enrolled as follows: 1. Members determined to have a Serious Mental Illness will be enrolled with a RBHA, including members with a CRS designation and KidsCare members; with the exception of members determined to have an SMI who opt to transfer from a RBHA to an AHCCCS Complete Care Contractor for the provision of physical health services only as outlined in AHCCCS ACOM Policy 442. 2. Children in State custody will be enrolled in DCS/CMDP to receive physical health services including CRS services and will be assigned to a RBHA for provision of behavioral health services. 3. Members eligible for Arizona Long Term Care System will be enrolled with DES/DDD or an ALTCS E/PD Contractor, as applicable. Members who do not choose a Contractor prior to AHCCCS being notified of their eligibility are automatically assigned to a Contractor based on re-enrollment rules, family continuity, or the auto-assignment algorithm. If a member is auto-assigned, AHCCCS sends a Choice Notice to the member and allows the member 90 days to choose a different Contractor. See Section D, Paragraph 6, Auto-Assignment Algorithm, for further explanation. American Indians: The American Indian Health Program (AIHP) is responsible for

Effective Date: 7-1-18 Approval Date: 6 integrated care for American Indian adult and child members who select AIHP and who have not determined to have Seriously Mentally Ill. Integrated care services include both physical and behavioral health services, including services related to a CRS condition. American Indians not determined to be SMI can choose to enroll as follows: 1. In an AHCCCS Complete Care Contractor to receive both physical health services and behavioral services (adults 18 and over only), 2. In AIHP for physical and behavioral health services, and 3. In AIHP for physical health services and receive behavioral health services from a TRBHA. Indian Health Services/638 Tribal Facilities AHCCCS also enables KidsCare eligible Native American children to use the Indian Health Service or 638 facilities operated by tribal governments who want to participate in the program. Of course, a Native American child who is eligible for KidsCare may also elect to enroll with one of the available AHCCCS health plans or a participating state employee HMO. 3.1.1.2 Do any of your CHIP populations that receive services through a managed care delivery system receive any services outside of a managed care delivery system? No Yes If yes, please describe which services are carved out of your managed care delivery system and how the State provides these services to an enrollee, such as through fee-for-service. Examples of carved out services may include transportation and dental, among others. CHIP (Kidscare) members who are American Indian and who are enrolled in managed care may also receive services at IHS/638 facilities at any time. The claim will be reimbursed by the member’s enrolled health plan. 3.1.2 Use of a Managed Care Delivery System for All or Some of the State’s CHIP Populations 3.1.2.1 Check each of the types of entities below that the State will contract with under its managed care delivery system, and select and/or explain the method(s) of payment that the State will use:

Effective Date: 7-1-18 Approval Date: 7

Managed care organization (MCO) (42 CFR 457.10) Capitation payment

Describe population served:

All Title XXI eligible children receive services through an MCO, with the exception of American Indians who elect to receive services on a Fee-For-Service basis through AIHP.

Prepaid inpatient health plan (PIHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Prepaid ambulatory health plan (PAHP) (42 CFR 457.10) Capitation payment Other (please explain)

Describe population served:

Primary care case manager (PCCM) (individual practitioners) (42 CFR 457.10) Case management fee Other (please explain)

Primary care case management entity (PCCM Entity) (42 CFR 457.10) Case management fee Shared savings, incentive payments, and/or other financial rewards for improved quality outcomes (see 42 CFR 457.1240(f)) Other (please explain)

If PCCM entity is selected, please indicate which of the following function(s) the entity will provide (as described in 42 CFR 457.10), in addition to PCCM services: Provision of intensive telephonic case management Provision of face-to-face case management Operation of a nurse triage advice line Development of enrollee care plans Execution of contracts with fee-for-service (FFS) providers in the FFS program Oversight responsibilities for the activities of FFS providers in the FFS program Provision of payments to FFS providers on behalf of the State Provision of enrollee outreach and education activities Operation of a customer service call center

Effective Date: 7-1-18 Approval Date: 8

Review of provider claims, utilization and/or practice patterns to conduct provider profiling and/or practice improvement Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers Coordination with behavioral health systems/providers Other (please describe)

3.1.2.2

The State assures that if its contract with an MCO, PAHP, or PIHP allows the entity to use a physician incentive plan, the contract stipulates that the entity must comply with the requirements set forth in 42 CFR 422.208 and 422.210. (42 CFR 457.1201(h), cross-referencing to 42 CFR 438.3(i)) 3.2. General Managed Care Contract Provisions

3.2.1

The State assures that it provides for free and open competition, to the maximum extent practical, in the bidding of all procurement contracts for coverage or other services, including external quality review organizations, in accordance with the procurement requirements of 45 CFR part 75, as applicable. (42 CFR 457.940(b); 42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(e)) 3.2.2

The State assures that it will include provisions in all managed care contracts that define a sound and complete procurement contract, as required by 45 CFR part 75, as applicable. (42 CFR 457.940(c)) 3.2.3

The State assures that each MCO, PIHP, PAHP, PCCM, and PCCM entity complies with any applicable Federal and State laws that pertain to enrollee rights, and ensures that its employees and contract providers observe and protect those rights (42 CFR 457.1220, cross-referencing to 42 CFR 438.100). These Federal and State laws include: Title VI of the Civil Rights Act of 1964 (45 CFR part 80), Age Discrimination Act of 1975 (45 CFR part 91), Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, Titles II and III of the Americans with Disabilities Act, and section 1557 of the Patient Protection and Affordable Care Act. 3.2.4

The State assures that it operates a Web site that provides the MCO, PIHP, PAHP, and PCCM entity contracts. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(3)) 3.3 Rate Development Standards and Medical Loss Ratio

3.3.1 The State assures that its payment rates are:

Effective Date: 7-1-18 Approval Date: 9

Based on public or private payment rates for comparable services for comparable populations; and Consistent with actuarially sound principles as defined in 42 CFR 457.10. (42 CFR 457.1203(a))

If the State is unable to meet the requirements under 42 CFR 457.1203(a), the State attests that it must establish higher rates because such rates are necessary to ensure sufficient provider participation or provider access or to enroll providers who demonstrate exceptional efficiency or quality in the provision of services. (42 CFR 457.1203(b)) 3.3.2

The State assures that its rates are designed to reasonably achieve a medical loss ratio standard equal to at least 85 percent for the rate year and provide for reasonable administrative costs. (42 CFR 457.1203(c)) 3.3.3

The State assures that it will provide to CMS, if requested by CMS, a description of the manner in which rates were developed in accordance with the requirements of 42 CFR 457.1203(a) through (c). (42 CFR 457.1203(d)) 3.3.4

The State assures that it annually submits to CMS a summary description of the reports pertaining to the medical loss ratio received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(a)) 3.3.5 Does the State require an MCO, PIHP, or PAHP to pay remittances through the contract for not meeting the minimum MLR required by the State? (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b)(1)) No, the State does not require any MCO, PIHP, or PAHP to pay remittances. Yes, the State requires all MCOs, PIHPs, and PAHPs to pay remittances. Yes, the State requires some, but not all, MCOs, PIHPs, and PAHPs to pay remittances.

If the State requests some, but not all, MCOs, PIHPs, and PAHPs to pay remittances through the contract for not meeting the minimum MLR required by the State, please describe which types of managed care entities are and are not required to pay remittances. For example, if a state requires a medical MCO to pay a remittances but not a dental PAHP, please include this information. If the answer to the assurance above is yes for any or all managed care entities, please answer the next assurance:

Effective Date: 7-1-18 Approval Date: 10

The State assures that it if a remittance is owed by an MCO, PIHP, or PAHP to the State, the State: • Reimburses CMS for an amount equal to the Federal share of the remittance, taking into account applicable differences in the Federal matching rate; and • Submits a separate report describing the methodology used to determine the State and Federal share of the remittance with the annual report provided to CMS that summarizes the reports received from the MCOs, PIHPs, and PAHPs. (42 CFR 457.1203(e), cross referencing to 42 CFR 438.74(b))

3.3.6

The State assures that each MCO, PIHP, and PAHP calculates and reports the medical loss ratio in accordance with 42 CFR 438.8. (42 CFR 457.1203(f)) 3.4 Enrollment

The State assures that its contracts with MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities provide that the MCO, PIHP, PAHP, PCCM or PCCM entity: • Accepts individuals eligible for enrollment in the order in which they apply without restriction (unless authorized by CMS), up to the limits set under the contract (42 CFR 457.1201(d), cross-referencing to 42 CFR 438.3(d)(1)); • Will not, on the basis of health status or need for health care services, discriminate against individuals eligible to enroll (42 CFR 457.1201(d), cross- referencing to 42 CFR 438.3(d)(3)); and • Will not discriminate against individuals eligible to enroll on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, national origin, sex, sexual orientation, gender identity or disability. (42 CFR 457.1201(d), cross-referencing to 438.3(d)(4)) • 3.4.1 Enrollment Process 3.4.1.1

The State assures that it provides informational notices to potential enrollees in an MCO, PIHP, PAHP, PCCM, or PCCM entity that includes the available managed care entities, explains how to select an entity, explains the implications of making or not making an active choice of an entity, explains the length of the enrollment period as well as the disenrollment policies, and complies with the information requirements in 42 CFR 457.1207 and accessibility standards established under 42 CFR 457.340. (42 CFR 457.1210(c)) 3.4.1.2

The State assures that its enrollment system gives beneficiaries already enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM

Effective Date: 7-1-18 Approval Date: 11

entity priority to continue that enrollment if the MCO, PIHP, PAHP, PCCM, or PCCM entity does not have the capacity to accept all those seeking enrollment under the program. (42 CFR 457.1210(b)) 3.4.1.3 Does the State use a default enrollment process to assign beneficiaries to an MCO, PIHP, PAHP, PCCM, or PCCM entity? (42 CFR 457.1210(a)) Yes No

If the State uses a default enrollment process, please make the following assurances: The State assigns beneficiaries only to qualified MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities that are not subject to the intermediate sanction of having suspension of all new enrollment (including default enrollment) under 42 CFR 438.702 and have capacity to enroll beneficiaries. (42 CFR 457.1210(a)(1)(i)) The State maximizes continuation of existing provider- beneficiary relationships under 42 CFR 457.1210(a)(1)(ii) or if that is not possible, distributes the beneficiaries equitably and does not arbitrarily exclude any MCO, PIHP, PAHP, PCCM or PCCM entity from being considered. (42 CFR 457.1210(a)(1)(ii), 42 CFR 457.1210(a)(1)(iii))

3.4.2 Disenrollment 3.4.2.1

The State assures that the State will notify enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f)(2)) 3.4.2.2

The State assures that the effective date of an approved disenrollment, regardless of the procedure followed to request the disenrollment, will be no later than the first day of the second month following the month in which the enrollee requests disenrollment or the MCO, PIHP, PAHP, PCCM or PCCM entity refers the request to the State. (42 CFR 457.1212, cross- referencing to 438.56(e)(1)) 3.4.2.3

If a beneficiary disenrolls from an MCO, PIHP, PAHP, PCCM, or PCCM entity, the State assures that the beneficiary is provided the option to enroll in another plan or receive benefits from an alternative delivery system. (Section 2103(f)(3) of the Social Security Act, incorporating section 1932(a)(4); 42 CFR 457.1212,

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cross referencing to 42 CFR 438.56; State Health Official Letter #09-008) 3.4.2.4 MCO, PIHP, PAHP, PCCM and PCCM Entity Requests for Disenrollment. The State assures that contracts with MCOs, PIHPs, PAHPs, PCCMs and PCCM entities describe the reasons for which an MCO, PIHP, PAHP, PCCM and PCCM entity may request disenrollment of an enrollee, if any. (42 CFR 457.1212, cross- referencing to 42 CFR 438.56(b)) AHCCCS does not allow MCOs to dis-enroll members. 3.4.2.5 Enrollee Requests for Disenrollment. Does the State limit disenrollment from an MCO, PIHP, PAHP, PCCM and PCCM entity by an enrollee? (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)) Yes No

If the State limits disenrollment by the enrollee from an MCO, PIHP, PAHP, PCCM and PCCM entity, please make the following assurances (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)): The State assures that enrollees and their representatives are given written notice of disenrollment rights at least 60 days before the start of each enrollment period. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(1)) The State assures that beneficiary requests to disenroll for cause will be permitted at any time by the MCO, PIHP, PAHP, PCCM or PCCM entity. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(1) and (d)(2))

AHCCCS and the KidsCare program are exempt from strict compliance with some aspects of these provisions as described in Paragraph 1 of the 1115 demonstration waiver list.

The State assures that beneficiary requests for disenrollment without cause will be permitted by the MCO, PIHP, PAHP, PCCM or PCCM entity at the following times: • During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later; • At least once every 12 months thereafter; • If the State plan provides for automatic reenrollment for an

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individual who loses CHIP eligibility for a period of 2 months or less and the temporary loss of CHIP eligibility has caused the beneficiary to miss the annual disenrollment opportunity; and • When the State imposes the intermediate sanction on the MCO, PIHP, PAHP, PCCM or PCCM entity specified in 42 CFR 438.702(a)(4). (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(c)(2)) 3.4.2.6

The State assures that the State ensures timely access to a State review for any enrollee dissatisfied with a State agency determination that there is not good cause for disenrollment. (42 CFR 457.1212, cross-referencing to 42 CFR 438.56(f)(2)) 3.5 Information Requirements for Enrollees and Potential Enrollees 3.5.1

The State assures that it provides, or ensures its contracted MCOs, PAHPs, PIHPs, PCCMs and PCCM entities provide, all enrollment notices, informational materials, and instructional materials related to enrollees and potential enrollees in accordance with the terms of 42 CFR 457.1207, cross-referencing to 42 CFR 438.10. 3.5.2

The State assures that all required information provided to enrollees and potential enrollees are in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(1)) 3.5.3

The State assures that it operates a Web site that provides the content specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)-(i) either directly or by linking to individual MCO, PIHP, PAHP and PCCM entity Web sites. 3.5.4

The State assures that it has developed and requires each MCO, PIHP, PAHP and PCCM entity to use: • Definitions for the terms specified under 42 CFR 438.10(c)(4)(i), and • Model enrollee handbooks, and model enrollee notices. (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(4))

3.5.5

If the State, MCOs, PIHPs, PAHPs, PCCMs or PCCM entities provide the information required under 42 CFR 457.1207 electronically, check this box to confirm that the State assures that it meets the requirements under 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(c)(6) for providing the material in an accessible manner. Including that: • The format is readily accessible; • The information is placed in a location on the State, MCO's, PIHP's, PAHP's, or PCCM's, or PCCM entity's Web site that is prominent and readily accessible; • The information is provided in an electronic form which can be

Effective Date: 7-1-18 Approval Date: 14

electronically retained and printed; • The information is consistent with the content and language requirements in 42 CFR 438.10; and • The enrollee is informed that the information is available in paper form without charge upon request and is provided the information upon request within 5 business days. 3.5.6

The State assures that it meets the language and format requirements set forth in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(d), including but not limited to: • Establishing a methodology that identifies the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, and in each MCO, PIHP, PAHP, or PCCM entity service area; • Making oral interpretation available in all languages and written translation available in each prevalent non-English language; • Requiring each MCO, PIHP, PAHP, and PCCM entity to make its written materials that are critical to obtaining services available in the prevalent non-English languages in its particular service area; • Making interpretation services available to each potential enrollee and requiring each MCO, PIHP, PAHP, and PCCM entity to make those services available free of charge to each enrollee; and • Notifying potential enrollees, and requiring each MCO, PIHP, PAHP, and PCCM entity to notify its enrollees: o That oral interpretation is available for any language and written translation is available in prevalent languages; o That auxiliary aids and services are available upon request and at no cost for enrollees with disabilities; and o How to access the services in 42 CFR 457.1207, cross-referencing 42 CFR 438.10(d)(5)(i) and (ii).

3.5.7

The State assures that the State or its contracted representative provides the information specified in 42 CFR 457.1207, cross-referencing to 438.10(e)(2), and includes the information either in paper or electronic format, to all potential enrollees at the time the potential enrollee becomes eligible to enroll in a voluntary managed care program or is first required to enroll in a mandatory managed care program and within a timeframe that enables the potential enrollee to use the information to choose among the available MCOs, PIHPs, PAHPs, PCCMs and PCCM entities: • Information about the potential enrollee's right to disenroll consistent with the requirements of 42 CFR 438.56 and which explains clearly the process for exercising this disenrollment right, as well as the alternatives available to the potential enrollee based on their specific circumstance; • The basic features of managed care; • Which populations are excluded from enrollment in managed care, subject to mandatory enrollment, or free to enroll voluntarily in the

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program; • The service area covered by each MCO, PIHP, PAHP, PCCM, or PCCM entity; • Covered benefits including: o Which benefits are provided by the MCO, PIHP, or PAHP; and which, if any, benefits are provided directly by the State; and o For a counseling or referral service that the MCO, PIHP, or PAHP does not cover because of moral or religious objections, where and how to obtain the service; • The provider directory and formulary information required in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h) and (i); • Any cost-sharing for the enrollee that will be imposed by the MCO, PIHP, PAHP, PCCM, or PCCM entity consistent with those set forth in the State plan; • The requirements for each MCO, PIHP or PAHP to provide adequate access to covered services, including the network adequacy standards established in 42 CFR 457.1218, cross-referencing 42 CFR 438.68; • The MCO, PIHP, PAHP, PCCM and PCCM entity's responsibilities for coordination of enrollee care; and • To the extent available, quality and performance indicators for each MCO, PIHP, PAHP and PCCM entity, including enrollee satisfaction. AHCCCS and the KidsCare program are exempt from strict compliance with some aspects of these provisions as described in Paragraph 1 of the 1115 demonstration waiver list. 3.5.8

The State assures that it will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that the State must notify all enrollees of their right to disenroll consistent with the requirements of 42 CFR 438.56 at least annually. 3.5.9

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide the information specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(f) to all enrollees of MCOs, PIHPs, PAHPs and PCCM entities, including that: • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity, must make a good faith effort to give written notice of termination of a contracted provider within the timeframe specified in 42 CFR 438.10(f), and • The MCO, PIHP, PAHP and, when appropriate, the PCCM entity must make available, upon request, any physician incentive plans in place as set forth in 42 CFR 438.3(i).

3.5.10

The State assures that each MCO, PIHP, PAHP and PCCM entity will provide enrollees of that MCO, PIHP, PAHP or PCCM entity an enrollee

Effective Date: 7-1-18 Approval Date: 16

handbook that meets the requirements as applicable to the MCO, PIHP, PAHP and PCCM entity, specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(g)(1)-(2), within a reasonable time after receiving notice of the beneficiary's enrollment, by a method consistent with 42 CFR 438.10(g)(3), and including the following items: • Information that enables the enrollee to understand how to effectively use the managed care program, which, at a minimum, must include: o Benefits provided by the MCO, PIHP, PAHP or PCCM entity; o How and where to access any benefits provided by the State, including any cost sharing, and how transportation is provided; and o In the case of a counseling or referral service that the MCO, PIHP, PAHP, or PCCM entity does not cover because of moral or religious objections, the MCO, PIHP, PAHP, or PCCM entity must inform enrollees that the service is not covered by the MCO, PIHP, PAHP, or PCCM entity and how they can obtain information from the State about how to access these services; • The amount, duration, and scope of benefits available under the contract in sufficient detail to ensure that enrollees understand the benefits to which they are entitled; • Procedures for obtaining benefits, including any requirements for service authorizations and/or referrals for specialty care and for other benefits not furnished by the enrollee's primary care provider; • The extent to which, and how, after-hours and emergency coverage are provided, including: o What constitutes an emergency medical condition and emergency services; o The fact that prior authorization is not required for emergency services; and o The fact that, subject to the provisions of this section, the enrollee has a right to use any hospital or other setting for emergency care; • Any restrictions on the enrollee's freedom of choice among network providers; • The extent to which, and how, enrollees may obtain benefits, including family planning services and supplies from out-of- network providers; • Cost sharing, if any is imposed under the State plan; • Enrollee rights and responsibilities, including the elements specified in 42 CFR §438.100; • The process of selecting and changing the enrollee's primary

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care provider; • Grievance, appeal, and review procedures and timeframes, consistent with 42 CFR 457.1260, in a State-developed or State- approved description, including: o The right to file grievances and appeals; o The requirements and timeframes for filing a grievance or appeal; o The availability of assistance in the filing process; and o The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; • How to access auxiliary aids and services, including additional information in alternative formats or languages; • The toll-free telephone number for member services, medical management, and any other unit providing services directly to enrollees; and • Information on how to report suspected fraud or abuse. 3.5.11

The State assures that each MCO, PIHP, PAHP and PCCM entity will give each enrollee notice of any change that the State defines as significant in the information specified in the enrollee handbook at least 30 days before the intended effective date of the change. (42 CFR 457.1207, cross- referencing to 42 CFR 438.10(g)(4)) 3.5.12

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available a provider directory for the MCO’s, PIHP’s, PAHP’s or PCCM entity’s network providers, including for physicians (including specialists), hospitals, pharmacies, and behavioral health providers, that includes information as specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(1)-(2) and (4). 3.5.13

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will update any information included in a paper provider directory at least monthly and in an electronic provider directories as specified in 42 CFR 438.10(h)(3). (42 CFR 457.1207, cross-referencing to 42 CFR 438.10(h)(3)) 3.5.14

The State assures that each MCO, PIHP, PAHP and when appropriate, PCCM entity, will make available the MCO’s, PIHP’s, PAHP’s, or PCCM entity’s formulary that meets the requirements specified in 42 CFR 457.1207, cross-referencing to 42 CFR 438.10(i), including: • Which medications are covered (both generic and name brand); and • What tier each medication is on. 3.5.15

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity follows the requirements for marketing activities under 42 CFR 457.1224, cross-referencing to 42 CFR 438.104 (except 42 CFR 438.104(c)).

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3.5.16

The State assures that each MCO, PIHP and PAHP protects communications between providers and enrollees under 42 CFR 457.1222, cross-referencing to 42 CFR 438.102. 3.5.17

The State assures that MCOs, PIHPs, and PAHPs have arrangements and procedures that prohibit the MCO, PIHP, and PAHP from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity. (42 CFR 457.1280(b)(2)) 3.5.18

The State assures that each contracted MCO, PIHP, and PAHP comply with the notice requirements specified for grievances and appeals in accordance with the terms of 42 CFR 438, Subpart F, except that the terms of 42 CFR 438.420 do not apply and that references to reviews should be read to refer to reviews as described in 42 CFR 457, Subpart K. (42 CFR 457.1260) 3.6 Benefits and Services

3.6.1

The State assures that MCO, PIHP, PAHP, PCCM entity, and PCCM contracts involving Indians, Indian health care providers, and Indian managed care entities comply with the requirements of 42 CFR 438.14. (42 CFR 457.1209)

CHIP (Kidscare) members are not a qualified population for enrollment in the American Indian Medical Home (PCCM) program. AHCCCS and the KidsCare program have authority to claim expenditures for capitation even though MCOs do not necessarily comply with 4398.14. See Paragraph 3 of the list of Expenditure Authorities approved as part of the 1115 demonstration. 3.6.2

The State assures that all services covered under the State plan are available and accessible to enrollees. (42 CFR 457.1230(a), cross- referencing to 42 CFR 438.206) 3.6.3

The State assures that it: • Publishes the State’s network adequacy standards developed in accordance with 42 CFR 457.1218, cross-referencing 42 CFR 438.68(b)(1) on the Web site required by 42 CFR 438.10; • Makes available, upon request, the State’s network adequacy standards at no cost to enrollees with disabilities in alternate formats or through the provision of auxiliary aids and services. (42 CFR 457.1218, cross-referencing 42 CFR 438.68(e))

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3.6.4

The State assures that each MCO, PAHP and PIHP meet the State’s network adequacy standards. (42 CFR 457.1218, cross-referencing 42 CFR 438.68; 42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206) 3.6.5

The State assures that each MCO, PIHP, and PAHP includes within its network of credentialed providers: • A sufficient number of providers to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities; • Women’s health specialists to provide direct access to covered care necessary to provide women’s routine and preventative health care services for female enrollees; and • Family planning providers to ensure timely access to covered services. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b) 3.6.6

The State assures that each contract under 42 CFR 457.1201 permits an enrollee to choose his or her network provider. (42 CFR 457.1201(j), cross-referencing 42 CFR 438.3(l)) 3.6.7

The State assures that each MCO, PIHP, and PAHP provides for a second opinion from a network provider, or arranges for the enrollee to obtain one outside the network, at no cost. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(3)) 3.6.8

The State assures that each MCO, PIHP, and PAHP ensures that providers, in furnishing services to enrollees, provide timely access to care and services, including by: • Requiring the contract to adequately and timely cover out-of- network services if the provider network is unable to provide necessary services covered under the contract to a particular enrollee and at a cost to the enrollee that is no greater than if the services were furnished within the network; • Requiring the MCO, PIHP and PAHP meet and its network providers to meet State standards for timely access to care and services, taking into account the urgency of the need for services; • Ensuring that the hours of operation for a network provider are no less than the hours of operation offered to commercial enrollees or comparable to Medicaid or CHIP Fee-For-Service, if the provider serves only Medicaid or CHIP enrollees; • Ensuring that the MCO, PIHP and PAHP makes available services include in the contract on a 24 hours a day, 7 days a week basis when medically necessary; • Establishing mechanisms to ensure compliance by network

Effective Date: 7-1-18 Approval Date: 20

providers; • Monitoring network providers regularly to determine compliance; • Taking corrective action if there is a failure to comply by a network provider. (42 CFR 457.1230(a), cross-referencing to 42 CFR 438.206(b)(4) and (5) and (c)) 3.6.9

The State assures that each MCO, PIHP, and PAHP has the capacity to serve the expected enrollment in its service area in accordance with the State's standards for access to care. (42 CFR 457.1230(b), cross- referencing to 42 CFR 438.207) 3.6.10

The State assures that each MCO, PIHP, and PAHP will be required to submit documentation to the State, at the time of entering into a contract with the State, on an annual basis, and at any time there has been a significant change to the MCO, PIHP, or PAHP’s operations that would affect the adequacy of capacity and services, to demonstrate that each MCO, PIHP, and PAHP for the anticipated number of enrollees for the service area: • Offers an appropriate range of preventative, primary care and specialty services; and • Maintains a provider network that is sufficient in number, mix, and geographic distribution. (42 CFR 457.1230, cross- referencing to 42 CFR 438.207(b)) 3.6.11

Except that 42 CFR 438.210(a)(5) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the coverage of services requirements under 42 CFR 438.210, including: • Identifying, defining, and specifying the amount, duration, and scope of each service that the MCO, PIHP, or PAHP is required to offer; and • Permitting an MCO, PIHP, or PAHP to place appropriate limits on a service. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(a) except that 438.210(a)(5) does not apply to CHIP contracts) 3.6.12

Except that 438.210(b)(2)(iii) does not apply to CHIP, the State assures that its contracts with each MCO, PIHP, or PAHP comply with the authorization of services requirements under 42 CFR 438.210, including that: • The MCO, PIHP, or PAHP and its subcontractors have in place and follow written policies and procedures; • The MCO, PIHP, or PAHP have in place mechanisms to ensure consistent application of review criteria and consult with the requesting provider when appropriate; and • Any decision to deny a service authorization request or to

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authorize a service in an amount, duration, or scope that is less than requested be made by an individual with appropriate expertise in addressing the enrollee’s medical, or behavioral health needs. (42 CFR 457.1230(d), cross referencing to 42 CFR 438.210(b), except that 438.210(b)(2)(iii) does not apply to CHIP contracts) 3.6.13

The State assures that its contracts with each MCO, PIHP, or PAHP require each MCO, PIHP, or PAHP to notify the requesting provider and given written notice to the enrollee of any adverse benefit determination to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 CFR 457.1230(d), cross-referencing to 42 CFR 438.210(c)) 3.6.14

The State assures that its contracts with each MCO, PIHP, or PAHP provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee. (42 CFR 457.1230(d), cross- referencing to 42 CFR 438.210(e)) 3.6.15

The State assures that it has a transition of care policy that meets the requirements of 438.62(b)(1) and requires that each contracted MCO, PIHP, and PAHP implements the policy. (42 CFR 457.1216, cross- referencing to 42 CFR 438.62) 3.6.16

The State assures that each MCO, PIHP, and PAHP has implemented procedures to deliver care to and coordinate services for all enrollees in accordance with 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208, including: • Ensure that each enrollee has an ongoing source of care appropriate to his or her needs; • Ensure that each enrollee has a person or entity formally designated as primarily responsible for coordinating the services accessed by the enrollee; • Provide the enrollee with information on how to contract their designated person or entity responsible for the enrollee’s coordination of services; • Coordinate the services the MCO, PIHP, or PAHP furnishes to the enrollee between settings of care; with services from any other MCO, PIHP, or PAHP; with fee-for-service services; and with the services the enrollee receives from community and social support providers; • Make a best effort to conduct an initial screening of each enrollees needs within 90 days of the effective date of enrollment for all new enrollees; • Share with the State or other MCOs, PIHPs, or PAHPs serving

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the enrollee the results of any identification and assessment of the enrollee’s needs; • Ensure that each provider furnishing services to enrollees maintains and shares, as appropriate, an enrollee health record in accordance with professional standards; and • Ensure that each enrollee’s privacy is protected in the process of coordinating care is protected with the requirements of 45 CFR parts 160 and 164 subparts A and E. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(b)) 3.6.17

The State assures that it has implemented mechanisms for identifying to MCOs, PIHPs, and PAHPs enrollees with special health care needs who are eligible for assessment and treatment services under 42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c) and included the mechanism in the State’s quality strategy. 3.6.18

The State assures that each applicable MCO, PIHP, and PAHP implements the mechanisms to comprehensively assess each enrollee identified by the state as having special health care needs. (42 CFR 457.1230(c), cross- referencing to 42 CFR 438.208(c)(2)) 3.6.19

The State assures that each MCO, PIHP, and PAHP will produce a treatment or service plan that meets the following requirements for enrollees identified with special health care needs: • Is in accordance with applicable State quality assurance and utilization review standards; • Reviewed and revised upon reassessment of functional need, at least every 12 months, or when the enrollee’s circumstances or needs change significantly. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(3)) 3.6.20

The State assures that each MCO, PIHP, and PAHP must have a mechanism in place to allow enrollees to directly access a specialist as appropriate for the enrollee's condition and identified needs for enrollees identified with special health care needs who need a course of treatment or regular care monitoring. (42 CFR 457.1230(c), cross-referencing to 42 CFR 438.208(c)(4)) 3.7 Operations 3.7.1

The State assures that it has established a uniform credentialing and recredentialing policy that addresses acute, primary, behavioral, and substance use disorders providers and requires each MCO, PIHP and PAHP to follow those policies. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(b)(1))

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3.7.2 The State assures each contracted MCO, PIHP and PAHP will comply with the provider selection requirements in 42 CFR 457.1208 and 457.1233(a), cross-referencing 42 CFR 438.12 and 438.214, including that: Each MCO, PIHP, or PAHP implements written policies and procedures for selection and retention of network providers (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(a)); MCO, PIHP, and PAHP network provider selection policies and procedures do not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(c)); MCOs, PIHPs, and PAHPs do not discriminate in the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification, solely on the basis of that license or certification (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); If an MCO, PIHP, or PAHP declines to include individual or groups of providers in the MCO, PIHP, or PAHP’s provider network, the MCO, PIHP, and PAHP gives the affected providers written notice of the reason for the decision (42 CFR 457.1208, cross referencing 42 CFR 438.12(a)); and MCOs, PIHPs, and PAHPs do not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. (42 CFR 457.1233(a), cross-referencing 42 CFR 438.214(d)).

3.7.3 The State assures that each contracted MCO, PIHP, and PAHP complies with the subcontractual relationships and delegation requirements in 42 CFR 457.1233(b), cross-referencing 42 CFR 438.230, including that: The MCO, PIHP, or PAHP maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its contract with the State; All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor specify that all delegated activities or obligations, and related reporting responsibilities, are specified in the contract or written agreement, the subcontractor agrees to perform the delegated activities and reporting responsibilities specified in compliance with the MCO's, PIHP's, or PAHP's contract obligations, and the contract or written arrangement must either provide for revocation of the delegation of activities or obligations, or specify other remedies in instances where the State or the MCO, PIHP, or PAHP determine that the subcontractor has not performed satisfactorily;

Effective Date: 7-1-18 Approval Date: 24

All contracts or written arrangements between the MCO, PIHP, or PAHP and any subcontractor must specify that the subcontractor agrees to comply with all applicable CHIP laws, regulations, including applicable subregulatory guidance and contract provisions; and The subcontractor agrees to the audit provisions in 438.230(c)(3). 3.7.4

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP, adopts and disseminates practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field; consider the needs of the MCO's, PIHP's, or PAHP's enrollees; are adopted in consultation with network providers; and are reviewed and updated periodically as appropriate. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(b) and (c)) 3.7.5

The State assures that each contracted MCO and, when applicable, each PIHP and PAHP makes decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines. (42 CFR 457.1233(c), cross referencing 42 CFR 438.236(d)) 3.7.6

The State assures that each contracted MCO, PIHP, and PAHP maintains a health information system that collects, analyzes, integrates, and reports data consistent with 42 CFR 438.242. The systems must provide information on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollments for other than loss of CHIP eligibility. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.7

The State assures that it reviews and validates the encounter data collected, maintained, and submitted to the State by the MCO, PIHP, or PAHP to ensure it is a complete and accurate representation of the services provided to the enrollees under the contract between the State and the MCO, PIHP, or PAHP and meets the requirements 42 CFR 438.242 of this section. (42 CFR 457.1233(d), cross referencing 42 CFR 438.242) 3.7.8

The State assures that it will submit to CMS all encounter data collected, maintained, submitted to the State by the MCO, PIHP, and PAHP once the State has reviewed and validated the data based on the requirements of 42 CFR 438.242. (CMS State Medicaid Director Letter #13-004) 3.7.9

The State assures that each contracted MCO, PIHP and PAHP complies with the privacy protections under 42 CFR 457.1110. (42 CFR 457.1233(e)) 3.8 Beneficiary Protections

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3.8.1

The State assures that each MCO, PIHP, PAHP, PCCM and PCCM entity has written policies regarding the enrollee rights specified in 42 CFR 438.100. (42 CFR 457.1220, cross-referencing to 42 CFR 438.100(a)(1)) 3.8.2

The State assures that its contracts with an MCO, PIHP, PAHP, PCCM, or PCCM entity include a guarantee that the MCO, PIHP, PAHP, PCCM, or PCCM entity will not avoid costs for services covered in its contract by referring enrollees to publicly supported health care resources. (42 CFR 457.1201(p)) 3.8.3

The State assures that MCOs, PIHPs, and PAHPs do not hold the enrollee liable for the following: • The MCO’s, PIHP’s or PAHP’s debts, in the event of the entity’s solvency. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(a)) • Covered services provided to the enrollee for which the State does not pay the MCO, PIHP or PAHP or for which the State, MCO, PIHP, or PAHP does not pay the individual or the health care provider that furnished the services under a contractual, referral or other arrangement. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(b)) • Payments for covered services furnished under a contract, referral or other arrangement that are in excess of the amount the enrollee would owe if the MCO, PIHP or PAHP covered the services directly. (42 CFR 457.1226, cross-referencing to 42 CFR 438.106(c)) 3.9 Grievances and Appeals 3.9.1

The State assures that each MCO, PIHP, and PAHP has a grievance and appeal system in place that allows enrollees to file a grievance and request an appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)) 3.9.2

The State assures that each MCO, PIHP, and PAHP has only one level of appeal for enrollees. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(b)) 3.9.3

The State assures that an enrollee may request a State review after receiving notice that the adverse benefit determination is upheld, or after an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 438.402(c)) 3.9.4. Does the state offer and arrange for an external medical review? Yes No

3.9.5

The State assures that the external medical review is:

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• At the enrollee's option and not required before or used as a deterrent to proceeding to the State review; • Independent of both the State and MCO, PIHP, or PAHP; • Offered without any cost to the enrollee; and • Not extending any of the timeframes specified in 42 CFR 438.408. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(1)(i)) 3.9.6

The State assures that an enrollee may file a grievance with the MCO, PIHP, or PAHP at any time. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(i)) 3.9.7

The State assures that an enrollee has 60 calendar days from the date on an adverse benefit determination notice to file a request for an appeal to the MCO, PIHP, or PAHP. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(2)(ii)) 3.9.8

The State assures that an enrollee may file a grievance and request an appeal either orally or in writing. (42 CFR 457.1260, cross-referencing to 42 CFR 438.402(a) and 438.402(c)(3)(i)) 3.9.9

The State assures that each MCO, PIHP, and PAHP gives enrollees timely and adequate notice of an adverse benefit determination in writing consistent with the requirements below in Section 3.9.10 and in 42 CFR 438.10. 3.9.10

The State assures that the notice of an adverse benefit determination explains: • The adverse benefit determination. • The reasons for the adverse benefit determination, including the right of the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the enrollee's adverse benefit determination. Such information includes medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits. • The enrollee's right to request an appeal of the MCO's, PIHP's, or PAHP's adverse benefit determination, including information on exhausting the MCO's, PIHP's, or PAHP's one level of appeal and the right to request a State review. • The procedures for exercising the rights specified above under this assurance. • The circumstances under which an appeal process can be expedited and how to request it. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(b))

Effective Date: 7-1-18 Approval Date: 27 3.9.11 The State assures that the notice of an adverse benefit determination is provided in a timely manner in accordance with 42 CFR 457.1260. (42 CFR 457.1260, cross-referencing to 42 CFR 438.404(c)) 3.9.12 The State assures that MCOs, PIHPs, and PAHPs give enrollees reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, auxiliary aids and services upon request, such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(a)) 3.9.13 The state makes the following assurances related to MCO, PIHP, and PAHP processes for handling enrollee grievances and appeals: Individuals who make decisions on grievances and appeals were neither involved in any previous level of review or decision-making nor a subordinate of any such individual. Individuals who make decisions on grievances and appeals, if deciding any of the following, are individuals who have the appropriate clinical expertise in treating the enrollee's condition or disease: • An appeal of a denial that is based on lack of medical necessity. • A grievance regarding denial of expedited resolution of an appeal. • A grievance or appeal that involves clinical issues. All comments, documents, records, and other information submitted by the enrollee or their representative will be taken into account, without regard to whether such information was submitted or considered in the initial adverse benefit determination. Enrollees have a reasonable opportunity, in person and in writing, to present evidence and testimony and make legal and factual arguments. Enrollees are provided the enrollee's case file, including medical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by the MCO, PIHP or PAHP (or at the direction of the MCO, PIHP or PAHP) in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals. The enrollee and his or her representative or the legal representative of a deceased enrollee's estate are included as parties to the appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.406(b)) 3.9.14 The State assures that standard grievances are resolved (including notice to the affected parties) within 90 calendar days from the day the MCO,

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PIHP, or PAHP receives the grievance. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b)) 3.9.15

The State assures that standard appeals are resolved (including notice to the affected parties) within 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal. The MCO, PIHP, or PAHP may extend the timeframe by up to 14 calendar days if the enrollee requests the extension or the MCO, PIHP, or PAHP shows that there is need for additional information and that the delay is in the enrollee's interest. (42 CFR 457.1260, cross-referencing to 42 CFR 42 CFR 438.408(b) and (c)) 3.9.16

The State assures that each MCO, PIHP, and PAHP establishes and maintains an expedited review process for appeals that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal. The expedited review process applies when the MCO, PIHP, or PAHP determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. (42 CFR 457.1260, cross- referencing to 42 CFR 438.408(b) and (c), and 42 CFR 438.410(a)) 3.9.17

The State assures that if an MCO, PIHP, or PAHP denies a request for expedited resolution of an appeal, it transfers the appeal within the timeframe for standard resolution in accordance with 42 CFR 438.408(b)(2). (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(c)(1)) 3.9.18

The State assures that if the MCO, PIHP, or PAHP extends the timeframes for an appeal not at the request of the enrollee or it denies a request for an expedited resolution of an appeal, it completes all of the following: • Make reasonable efforts to give the enrollee prompt oral notice of the delay. • Within 2 calendar days give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision. • Resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c) and 42 CFR 438.410(c)) 3.9.19

The State assures that if an MCO, PIHP, or PAHP fails to adhere to the notice and timing requirements in this section, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process and the enrollee may initiate a State review. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(c)(3))

Effective Date: 7-1-18 Approval Date: 29

3.9.20

The State assures that has established a method that an MCO, PIHP, and PAHP will use to notify an enrollee of the resolution of a grievance and ensure that such methods meet, at a minimum, the standards described at 42 CFR 438.10. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(1)) 3.9.21

For all appeals, the State assures that each contracted MCO, PIHP, and PAHP provides written notice of resolution in a format and language that, at a minimum, meet the standards described at 42 CFR 438.10. The notice of resolution includes at least the following items: • The results of the resolution process and the date it was completed; and • For appeals not resolved wholly in favor of the enrollees: o The right to request a State review, and how to do so. o The right to request and receive benefits while the hearing is pending, and how to make the request. o That the enrollee may, consistent with State policy, be held liable for the cost of those benefits if the hearing decision upholds the MCO's, PIHP's, or PAHP's adverse benefit determination. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(i) and (e))

3.9.22

For notice of an expedited resolution, the State assures that each contracted MCO, PIHP, or PAHP makes reasonable efforts to provide oral notice, in addition to the written notice of resolution. (42 CFR 457.1260, cross referencing to 42 CFR 457.408(d)(2)(ii)) 3.9.23

The State assures that if it offers an external medical review: • The review is at the enrollee's option and is not required before or used as a deterrent to proceeding to the State review; • The review is independent of both the State and MCO, PIHP, or PAHP; and • The review is offered without any cost to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.408(f)) 3.9.24

The State assures that MCOs, PIHPs, and PAHPs do not take punitive action against providers who request an expedited resolution or support an enrollee's appeal. (42 CFR 457.1260, cross-referencing to 42 CFR 438.410(b)) 3.9.25

The State assures that MCOs, PIHPs, or PAHPs must provide information specified in 42 CFR 438.10(g)(2)(xi) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. This includes: • The right to file grievances and appeals; • The requirements and timeframes for filing a grievance or appeal; • The availability of assistance in the filing process;

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• The right to request a State review after the MCO, PIHP or PAHP has made a determination on an enrollee's appeal which is adverse to the enrollee; and • The fact that, when requested by the enrollee, benefits that the MCO, PIHP, or PAHP seeks to reduce or terminate will continue if the enrollee files an appeal or a request for State review within the timeframes specified for filing, and that the enrollee may, consistent with State policy, be required to pay the cost of services furnished while the appeal or State review is pending if the final decision is adverse to the enrollee. (42 CFR 457.1260, cross-referencing to 42 CFR 438.414) 3.9.26

The State assures that it requires MCOs, PIHPs, and PAHPs to maintain records of grievances and appeals and reviews the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the State quality strategy. The record must be accurately maintained in a manner accessible to the state and available upon request to CMS. (42 CFR 457.1260, cross-referencing to 42 CFR 438.416) 3.9.27

The State assures that if the MCO, PIHP, or PAHP, or the State review officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal was pending, the MCO, PIHP, or PAHP must authorize or provide the disputed services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. (42 CFR 457.1260, cross-referencing to 42 CFR 438.424(a)) 3.10 Program Integrity 3.10.1 The State assures that any entity seeking to contract as an MCO, PIHP, or PAHP under a separate child health program has administrative and management arrangements or procedures designed to safeguard against fraud and abuse, including:

Enforcing MCO, PIHP, and PAHP compliance with all applicable Federal and State statutes, regulations, and standards;

Prohibiting MCOs, PIHPs, or PAHPs from conducting any unsolicited personal contact with a potential enrollee by an employee or agent of the MCO, PAHP, or PIHP for the purpose of influencing the individual to enroll with the entity; and

Including a mechanism for MCOs, PIHPs, and PAHPs to report to the State, to CMS, or to the Office of Inspector General (OIG) as appropriate, information on violations of law by subcontractors, providers, or enrollees of an MCO, PIHP, or PAHP and other individuals. (42 CFR 457.1280)

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3.10.2

The State assures that it has in effect safeguards against conflict of interest on the part of State and local officers and employees and agents of the State who have responsibilities relating to the MCO, PIHP, or PAHP contracts or enrollment processes described in 42 CFR 457.1210(a). (42 CFR 457.1214, cross referencing 42 CFR 438.58) 3.10.3

The State assures that it periodically, but no less frequently than once every 3 years, conducts, or contracts for the conduct of, an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by, or on behalf of, each MCO, PIHP or PAHP. (42 CFR 457.1285, cross referencing 42 CFR 438.602(e)) 3.10.4

The State assures that it requires MCOs, PIHPs, PAHP, and or subcontractors (only to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims) implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following: • A compliance program that include all of the elements described in 42 CFR 438.608(a)(1); • Provision for prompt reporting of all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State; • Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility; • Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP; • Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis; • In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers; • Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid/CHIP program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit; and

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• Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with 42 CFR 455.23. (42 CFR 457.1285, cross referencing 42 CFR 438.608(a)) 3.10.5

The State assures that each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(2)) 3.10.6

The State assures that each MCO, PIHP, or PAHP reports annually to the State on their recoveries of overpayments. (42 CFR 457.1285, cross referencing 42 CFR 438.608(d)(3)) 3.10.7

The State assures that it screens and enrolls, and periodically revalidates, all network providers of MCOs, PIHPs, and PAHPs, in accordance with the requirements of part 455, subparts B and E. This requirement also extends to PCCMs and PCCM entities to the extent that the primary care case manager is not otherwise enrolled with the State to provide services to fee-for-service beneficiaries. (42 CFR 457.1285, cross referencing 42 CFR 438.602(b)(1) and 438.608(b)) 3.10.8

The State assures that it reviews the ownership and control disclosures submitted by the MCO, PIHP, PAHP, PCCM or PCCM entity, and any subcontractors. (42 CFR 457.1285, cross referencing 42 CFR 438.602(c)) 3.10.9

The State assures that it confirms the identity and determines the exclusion status of the MCO, PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any person with an ownership or control interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine checks of Federal databases. If the State finds a party that is excluded, the State promptly notifies the MCO, PIHP, PAHP, PCCM, or PCCM entity and takes action consistent with 42 CFR 438.610(c). (42 CFR 457.1285, cross referencing 42 CFR 438.602(d)) 3.10.10

The State assures that it receives and investigates information from whistleblowers relating to the integrity of the MCO, PIHP, PAHP, PCCM, or PCCM entity, subcontractors, or network providers receiving Federal funds under this part. (42 CFR 457.1285, cross referencing 42 CFR 438.602(f)) 3.10.11

The State assures that MCOs, PIHPs, PAHPs, PCCMs, or PCCM entities with which the State contracts are not located outside of the United States

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and that no claims paid by an MCO, PIHP, or PAHP to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (42 CFR 457.1285, cross referencing to 42 CFR 438.602(i); Section 1902(a)(80) of the Social Security Act) 3.10.12 The State assures that MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities submit to the State the following data, documentation, and information:

Encounter data in the form and manner described in 42 CFR 438.818.

Data on the basis of which the State determines the compliance of the MCO, PIHP, or PAHP with the medical loss ratio requirement described in 42 CFR 438.8.

Data on the basis of which the State determines that the MCO, PIHP or PAHP has made adequate provision against the risk of insolvency as required under 42 CFR 438.116.

Documentation described in 42 CFR 438.207(b) on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services, including the adequacy of the provider network, as set forth in 42 CFR 438.206.

Information on ownership and control described in 42 CFR 455.104 of this chapter from MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors as governed by 42 CFR 438.230.

The annual report of overpayment recoveries as required in 42 CFR 438.608(d)(3). (42 CFR 457.1285, cross referencing 42 CFR 438.604(a))

3.10.13 The State assures that:

It requires that the data, documentation, or information submitted in accordance with 42 CFR 457.1285, cross referencing 42 CFR 438.604(a), is certified in a manner that the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's Chief Executive Officer or Chief Financial Officer is ultimately responsible for the certification. (42 CFR 457.1285, cross referencing 42 CFR 438.606(a))

It requires that the certification includes an attestation that, based on best information, knowledge, and belief, the data, documentation, and information specified in 42 CFR 438.604 are accurate, complete, and truthful. (42 CFR 457.1285, cross referencing 42 CFR 438.606(b)); and

It requires the MCO, PIHP, PAHP, PCCM, or PCCM entity to submit the certification concurrently with the submission of the data, documentation, or information required in 42 CFR 438.604(a) and (b). (42 CFR 457.1285, cross referencing 42 CFR 438.604(c))

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3.10.14

The State assures that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors provides: written disclosure of any prohibited affiliation under 42 CFR 438.610, written disclosure of and information on ownership and control required under 42 CFR 455.104, and reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract. (42 CFR 457.1285, cross referencing 42 CFR 438.608(c)) 3.10.15

The State assures that services are provided in an effective and efficient manner. (Section 2101(a)) 3.10.16

The State assures that it operates a Web site that provides: • The documentation on which the State bases its certification that the MCO, PIHP or PAHP has complied with the State's requirements for availability and accessibility of services; • Information on ownership and control of MCOs, PIHPs, PAHPs, PCCMs, PCCM entities, and subcontractors; and • The results of any audits conducted under 42 CFR 438.602(e). (42 CFR 457.1285, cross-referencing to 42 CFR 438.602(g)). 3.11 Sanctions 3.11.1

The State assures that it has established intermediate sanctions that it may impose if it makes the determination that an MCO has acted or failed to act in a manner specified in 438.700(b)-(d). (42 CFR 457.1270, cross referencing 42 CFR 438.700) 3.11.2

The State assures that it will impose temporary management if it finds that an MCO has repeatedly failed to meet substantive requirements of part 457 subpart L. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.3

The State assures that if it imposes temporary management on an MCO, the State allows enrollees the right to terminate enrollment without cause and notifies the affected enrollees of their right to terminate enrollment. (42 CFR 457.1270, cross referencing 42 CFR 438.706(b)) 3.11.5

The State assures that before it imposes intermediate sanctions, it gives the affected entity timely written notice. (42 CFR 457.1270, cross referencing 42 CFR 438.710(a)) 3.11.6

The State assures that if it intends to terminate an MCO, PCCM, or PCCM entity, it provides a pre-termination hearing and written notice of the decision as specified in 42 CFR 438.710(b). If the decision to terminate is affirmed, the State assures that it gives enrollees of the MCO, PCCM or PCCM entity notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving CHIP services following the

Effective Date: 7-1-18 Approval Date: 35

effective date of termination. (42 CFR 457.1270, cross referencing 42 CFR 438.710(b)) 3.11.7

The State assures that it will give CMS written notice that complies with 42 CFR 438.724 whenever it imposes or lifts a sanction for one of the violations listed in 42 CFR 438.700. (42 CFR 457.1270, cross referencing 42 CFR 438.724) 3.12 Quality Measurement and Improvement; External Quality Review 3.12.1 Quality Strategy 3.12.1.1

The State assures that it will draft and implement a written quality strategy for assessing and improving the quality of health care and services furnished CHIP enrollees as described in 42 CFR 438.340(a). The quality strategy must include the following items: • The State-defined network adequacy and availability of services standards for MCOs, PIHPs, and PAHPs required by 42 CFR 438.68 and 438.206 and examples of evidence-based clinical practice guidelines the State requires in accordance with 42 CFR 438.236; • A description of: o The quality metrics and performance targets to be used in measuring the performance and improvement of each MCO, PIHP, and PAHP with which the State contracts, including but not limited to, the performance measures reported in accordance with 42 CFR 438.330(c); and o The performance improvement projects to be implemented in accordance with 42 CFR 438.330(d), including a description of any interventions the State proposes to improve access, quality, or timeliness of care for beneficiaries enrolled in an MCO, PIHP, or PAHP; • Arrangements for annual, external independent reviews, in accordance with 42 CFR 438.350, of the quality outcomes and timeliness of, and access to, the services covered under each contract; • A description of the State's transition of care policy required under 42 CFR 438.62(b)(3); • The State's plan to identify, evaluate, and reduce, to the extent practicable, health disparities based on age, race, ethnicity, sex, and primary language; • For MCOs, appropriate use of intermediate sanctions that, at a minimum, meet the requirements of subpart I of 42 CFR Part 438; • A description of how the State will assess the performance and quality outcomes achieved by each PCCM entity;

Effective Date: 7-1-18 Approval Date: 36

• The mechanisms implemented by the State to comply with 42 CFR 438.208(c)(1) (relating to the identification of persons with special health care needs); • Identification of the external quality review (EQR)-related activities for which the State has exercised the option under 42 CFR 438.360 (relating to nonduplication of EQR-related activities), and explain the rationale for the State's determination that the private accreditation activity is comparable to such EQR-related activities; • Identification of which quality measures and performance outcomes the State will publish at least annually on the Web site required under 42 CFR 438.10(c)(3); and • The State's definition of a “significant change” for the purposes of updating the quality strategy under 42 CFR 438.340(c)(3)(ii). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)) 3.12.1.2

The State assures that the goals and objectives for continuous quality improvement in the quality strategy are measurable and take into consideration the health status of all populations in the State served by the MCO, PIHP, and PAHP. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(2)) 3.12.1.3

The State assures that for purposes of the quality strategy, the State provides the demographic information for each CHIP enrollee to the MCO, PIHP or PAHP at the time of enrollment. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(b)(6)) 3.12.1.4

The State assures that it will review and update the quality strategy as needed, but no less than once every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)) 3.12.1.5

The State assures that its review and updates to the quality strategy will include an evaluation of the effectiveness of the quality strategy conducted within the previous 3 years and the recommendations provided pursuant to 42 CFR 438.364(a)(4). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(i) and (iii). 3.12.1.6

The State assures that it will submit to CMS: A copy of the initial quality strategy for CMS comment and feedback prior to adopting it in final; and • A copy of the revised strategy whenever significant changes are made to the document, or whenever significant changes occur within the State's CHIP program, including after the review and update required every 3 years. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(3)) 3.12.1.7

Before submitting the strategy to CMS for review, the State assures that when it drafts or revises the State’s quality strategy it

Effective Date: 7-1-18 Approval Date: 37

will: Make the strategy available for public comment; and • If the State enrolls Indians in the MCO, PIHP, or PAHP, consult with Tribes in accordance with the State's Tribal consultation policy. (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(1)) 3.12.1.8

The State assures that it makes the results of the review of the quality strategy (including the effectiveness evaluation) and the final quality strategy available on the Web site required under 42 CFR 438.10(c)(3). (42 CFR 457.1240(e), cross referencing to 42 CFR 438.340(c)(2)(ii) and (d)) 3.12.2 Quality Assessment and Performance Improvement Program 3.12.2.1 Quality Assessment and Performance Improvement Program: Measures and Projects 3.12.2.1.1 The State assures that it requires that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees as provided in 42 CFR 438.330, except that the terms of 42 CFR 438.330(d)(4) (related to dual eligibles) do not apply. The elements of the assessment and program include at least: • Standard performance measures specified by the State; • Any measures and programs required by CMS (42 CFR 438.330(a)(2); • Performance improvement projects that focus on clinical and non-clinical areas, as specified in 42 CFR 438.330(d); • Collection and submission of performance measurement data in accordance with 42 CFR 438.330(c); • Mechanisms to detect both underutilization and overutilization of services; and • Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under 42 CFR 457.1240(e) and Section 3.12.1 of this template). (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(b) and (c)(1))

3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports

Effective Date: 7-1-18 Approval Date: 38

on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) •

3.12.2.2 Quality Assessment and Performance Improvement Program: Reporting and Effectiveness 3.12.2.2.1 The State assures that each MCO, PIHP, and PAHP reports on the status and results of each performance improvement project conducted by the MCO, PIHP, and PAHP to the State as required by the State, but not less than once per year. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(d)(3)) 3.12.2.2.2 The State assures that it annually requires each MCO, PIHP, and PAHP to:

1) Measure and report to the State on its performance using the standard measures required by the State;

2) Submit to the State data specified by the State to calculate the MCO's, PIHP's, or PAHP's performance using the standard measures identified by the State; or

Effective Date: 7-1-18 Approval Date: 39

3) Perform a combination of options (1) and (2) of this assurance. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(c)(2))

3.12.2.2.3 The State assures that the State reviews, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP and PCCM entity. The State’s review must include: • The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report; and • The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects. (42 CFR 457.1240(b), cross referencing to 42 CFR 438.330(e)(1)) 3.12.3 Accreditation 3.12.3.1

The State assures that it requires each MCO, PIHP, and PAHP to inform the state whether it has been accredited by a private independent accrediting entity, and, if the MCO, PIHP, or PAHP has received accreditation by a private independent accrediting agency, that the MCO, PIHP, and PAHP authorizes the private independent accrediting entity to provide the State a copy of its recent accreditation review that includes the MCO, PIHP, and PAHP’s accreditation status, survey type, and level (as applicable); accreditation results, including recommended actions or improvements, corrective action plans, and summaries of findings; and expiration date of the accreditation. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(a) and (b)). 3.12.3.2

The State assures that it will make the accreditation status for each contracted MCO, PIHP, and PAHP available on the Web site required under 42 CFR 438.10(c)(3), including whether each MCO, PIHP, and PAHP has been accredited and, if applicable, the name of the accrediting entity, accreditation program, and accreditation level; and update this information at least annually. (42 CFR 457.1240(c), cross referencing to 42 CFR 438.332(c)) 3.12.4 Quality Rating

The State assures that it will implement and operate a quality rating system that issues an annual quality rating for each MCO, PIHP, and PAHP, which the State will prominently display on the Web site required under 42 CFR 438.10(c)(3), in accordance with the requirements set forth in 42 CFR 438.334. (42 CFR 457.1240(d)) 3.12.5 Quality Review

Effective Date: 7-1-18 Approval Date: 40

The State assures that each contract with a MCO, PIHP, PAHP, or PCCM entity requires that a qualified EQRO performs an annual external quality review (EQR) for each contracting MCO, PIHP, PAHP or PCCM entity, except as provided in 42 CFR 438.362. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(a)) 3.12.5.1 External Quality Review Organization 3.12.5.1.1 The State assures that it contracts with at least one external quality review organization (EQRO) to conduct either EQR alone or EQR and other EQR-related activities. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.356(a)) 3.12.5.1.2 The State assures that any EQRO used by the State to comply with 42 CFR 457.1250 must meet the competence and independence requirements of 42 CFR 438.354 and, if the EQRO uses subcontractors, that the EQRO is accountable for and oversees all subcontractor functions. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.354 and 42 CFR 438.356(b) through (d)) 3.12.5.2 External Quality Review-Related Activities 3.12.5.2.1 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(1)(i) through (iv) (relating to the validation of performance improvement projects, validation of performance measures, compliance review, and validation of network adequacy) will be conducted on all MCOs, PIHPs, or PAHPs. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(b)(1))

3.12.5.2.2 The State assures that if it elects to use nonduplication for any or all of the three mandatory EQR-related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will document the use of nonduplication in the State’s quality strategy. (42 CFR 457.1250(a), cross referencing 438.360, 438.358(b)(1)(i) through (b)(1)(iii), and 438.340) 3.12.5.2.3 The State assures that if the State elects to use nonduplication for any or all of the three mandatory EQR- related activities described at 42 CFR 438.358(b)(1)(i) – (iii), the State will ensure that all information from a Medicare or private accreditation review for an MCO, PIHP, or PAHP will be furnished to the EQRO for analysis and inclusion in the EQR technical report described in 42 CFR 438.364. ((42 CFR 457.1250(a), cross referencing to 42 CFR 438.360(b))

Effective Date: 7-1-18 Approval Date: 41

3.12.5.2.4 The State assures that the mandatory EQR-related activities described in 42 CFR 438.358(b)(2) (cross-referencing 42 CFR 438.358(b)(1)(ii) and (b)(1)(iii)) will be conducted on all PCCM entities, which include: • Validation of PCCM entity performance measures required in accordance with 42 CFR 438.330(b)(2) or PCCM entity performance measures calculated by the State during the preceding 12 months; and • A review, conducted within the previous 3-year period, to determine the PCCM entity’s compliance with the standards set forth in subpart D of 42 CFR part 438 and the quality assessment and performance improvement requirements described in 42 CFR 438.330. (42 CFR 457.1250(a), cross referencing to 438.358(b)(2))

3.12.5.3 External Quality Review Report 3.12.5.3.1 The State assures that data obtained from the mandatory and optional, if applicable, EQR-related activities in 42 CFR 438.358 is used for the annual EQR to comply with 42 CFR 438.350 and must include, at a minimum, the elements in §438.364(a)(2)(i) through (iv). (42 CFR 457.1250(a), cross referencing to 42 CFR 438.358(a)(2))

3.12.5.3.2 The State assures that only a qualified EQRO will produce the EQR technical report (42 CFR 438.364(c)(1)).

3.12.5.3.3 The State assures that in order for the qualified EQRO to perform an annual EQR for each contracting MCO, PIHP, PAHP or PCCM entity under 42 CFR 438.350(a) that the following conditions are met: • The EQRO has sufficient information to use in performing the review; • The information used to carry out the review must be obtained from the EQR-related activities described in 42 CFR 438.358 and, if applicable, from a private accreditation review as described in 42 CFR 438.360; • For each EQR-related activity (mandatory or optional), the information gathered for use in the EQR must include the elements described in 42 CFR 438.364(a)(2)(i) through (iv); and • The information provided to the EQRO in accordance with 42 CFR 438.350(b) is obtained through methods consistent with the protocols established by the Secretary in accordance with 42 CFR 438.352. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(b)

Effective Date: 7-1-18 Approval Date: 42

through (e)) 3.12.5.3.4 The State assures that the results of the reviews performed by a qualified EQRO of each contracting MCO, PIHP, PAHP, and PCCM entity are made available as specified in 42 CFR 438.364 in an annual detailed technical report that summarizes findings on access and quality of care. The report includes at least the following items: • A description of the manner in which the data from all activities conducted in accordance with 42 CFR 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2)); • For each EQR-related activity (mandatory or optional) conducted in accordance with 42 CFR 438.358: o Objectives; o Technical methods of data collection and analysis; o Description of data obtained, including validated performance measurement data for each activity conducted in accordance with 42 CFR 438.358(b)(1)(i) and (ii); and o Conclusions drawn from the data; • An assessment of each MCO's, PIHP's, PAHP's, or PCCM entity's strengths and weaknesses for the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Recommendations for improving the quality of health care services furnished by each MCO, PIHP, PAHP, or PCCM entity, including how the State can target goals and objectives in the quality strategy, under 42 CFR 438.340, to better support improvement in the quality, timeliness, and access to health care services furnished to CHIP beneficiaries; • Methodologically appropriate, comparative information about all MCOs, PIHPs, PAHPs, and PCCM entities, consistent with guidance included in the EQR protocols issued in accordance with 42 CFR 438.352(e); and • An assessment of the degree to which each MCO, PIHP, PAHP, or PCCM entity has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.350(f) and 438.364(a)) 3.12.5.3.5 The State assures that it does not substantively revise the content of the final EQR technical report without evidence

Effective Date: 7-1-18 Approval Date: 43

of error or omission. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(b)) 3.12.5.3.6 The State assures that it finalizes the annual EQR technical report by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(1)) 3.12.5.3.7 The State assures that it posts the most recent copy of the annual EQR technical report on the Web site required under 42 CFR 438.10(c)(3) by April 30th of each year. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(i)) 3.12.5.3.8 The State assures that it provides printed or electronic copies of the information specified in 42 CFR 438.364(a) for the annual EQR technical report, upon request, to interested parties such as participating health care providers, enrollees and potential enrollees of the MCO, PIHP, PAHP, or PCCM, beneficiary advocacy groups, and members of the general public. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(2)(ii)) 3.12.5.3.9 The State assures that it makes the information specified in 42 CFR 438.364(a) for the annual EQR technical report available in alternative formats for persons with disabilities, when requested. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(c)(3)) 3.12.5.3.10 The State assures that information released under 42 CFR 438.364 for the annual EQR technical report does not disclose the identity or other protected health information of any patient. (42 CFR 457.1250(a), cross referencing to 42 CFR 438.364(d))

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Arizona AZ-20-0012

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

September 3, 2020

Jami Snyder Director Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034

Dear Ms. Snyder:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number AZ-20-0012, has been approved. Through this SPA, Arizona has demonstrated compliance with section 5022 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. Additionally, this SPA clarifies Arizona’s policies regarding coverage of children aging out of CHIP during a public health emergency. This SPA has an effective date of July 1, 2019 and June 26, 2020, respectively.

Section 5022 of the SUPPORT Act added Section 2103(c)(5) to the Social Security Act (the Act) and requires child health and pregnancy related assistance to include coverage of services necessary to prevent, diagnose, and treat a broad range of behavioral health symptoms and disorders. Additionally, Section 2103(c)(5)(B) of the Act requires that these behavioral health services be delivered in a culturally and linguistically appropriate manner. Arizona demonstrated compliance by providing the necessary assurances and benefit descriptions that the state covers a range of behavioral health services in a culturally and linguistically appropriate manner.

Your Project Officer is Ms. Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16 7500 Security Boulevard Baltimore, MD 21244-1850 Telephone: (410) 786-3413 E-mail: Joyce.Jordan@cms.hhs.gov

Page 2 — Ms. Jami Snyder

If you have additional questions, please contact Meg Barry, Acting Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely, /Signed by Amy Lutzky/

Amy Lutzky Acting Deputy Director

Original Implementation date:

November 1, 1998

Amendment Effective date:

February 1, 2004 (premiums >150% FPL)

July 1, 2004 (premiums 100%-150% FPL) May 1, 2009 (premiums >150% FPL) January 1, 2010 (enrollment cap) October 10, 2013 (remove wait list) July 26, 2016 (remove enrollment cap) August 6, 2016 (premium lock out period) October 1, 2017 (mental health parity) July 1, 2018 (Managed Care Regulations) January 27, 2020 (COVID-19 Disaster Response) July 1, 2019 (SUPPORT Act BH Services)

Discontinuation of coverage of children aging out of CHIP during the COVID public health emergency became effective on June 26, 2020.

In the event of a disaster, the State will notify CMS of its intent to provide temporary adjustments to; flexibilities around delays in processing applications and renewals, the ability to waive the three month waiting period for applicants, the ability to waive existing premiums, and the ability to waive the premium lock-out period. In addition, the state is requesting to temporarily provide continuous eligibility to its CHIP population.

1.4-TC Tribal Consultation (Section 2107 (e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred, and who was involved.

The State of Arizona seeks advice on a regular, ongoing basis from all of the federally-recognized tribes, Indian Health Service (IHS) Area Offices, tribal health programs operated under P.L. 93- 638, and urban Indian health programs in Arizona regarding Medicaid and CHIP matters. These matters include but are not limited to State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals, and proposals for demonstration projects. The AHCCCS Tribal Consultation Policy serves as a guidance document that includes the process by which reasonable notice and opportunity for consultation should occur and scenarios in which AHCCCS shall engage in the consultative process.

The frequency of consultation is dependent on the frequency in which policy changes are proposed. When a proposed policy change requires consultation, the State will to its best ability provide notice of the tribal consultation meeting date as well as a description of the proposed policy change to be discussed. Ideally, a consultation meeting, which provides an opportunity for discussion and verbal comments to be made regarding a proposed change, will occur either in-person or by conference call 45 days prior to the submission of the policy change to CMS. The State will also provide an opportunity for written comments. Ideally, during the 45-day period, tribes and I/T/U will be provided at least 30 days to submit written comments regarding the policy change for consideration. Verbal comments presented at the meeting as well as written comments will be included in an attachment to accompany the submission of a State Plan Amendment, waiver proposal, waiver renewal, or proposal for a demonstration project.

To address the COVID-19 public health emergency, the State seeks a waiver under section 1135 of the Act to modify the tribal consultation process by shortening the number of days before submission of the SPA and/or conducting consultation after submission of the SPA.

Effective Date: 7-1-19

3

Approval Date:

Effective Date: 1-27-20 5

Approval Date:

Once the application is approved, the applicant is enrolled with their chosen provider and AHCCCS sends a notice confirming the choice and a member identification card to the member. Following enrollment, the contractor provides a member handbook to the member, which contains important information about how to access health care for KidsCare eligible children.

AHCCCS approves a newborn of a mother who is eligible for KidsCare on the date the child is born. The newborn’s KidsCare eligibility begins with the newborn’s date of birth. Once approved for KidsCare, AHCCCS enrolls the newborn with the mother’s health plan. AHCCCS notifies the mother by mail of the newborn’s enrollment into KidsCare and is given an opportunity to change health plans at that time.

A member is allowed to change contractors on an annual basis and when an individual moves into a new geographic area not served by the current contractor. A member can change PCPs at any time. The option to change contractors is based on the member’s anniversary date, which is the first day of the month that the member is enrolled into KidsCare. Ten months following the anniversary date, the member will be sent an annual enrollment notice advising that a different contractor may be selected. A list of contractors, with toll-free numbers and the available services, is included. The member, or parent of the child, has three weeks to change contractors. If a change is requested, the effective date is a year from the anniversary date. Enrollees must notify AHCCCS of a change in address or other circumstances that could affect continued eligibility or enrollment.

American Indian children who elect to enroll with the American Indian Health Program are allowed to disenroll at any time upon request and choose a contractor for all KidsCare services. Similarly, American Indian children enrolled with a contractor or other providers are allowed to disenroll at any time upon request and enroll with the American Indian Health Program.

At State discretion, requirements related to timely processing of applications may be temporarily waived for CHIP applicants who reside and/or work in a State or Federally declared disaster area for the duration of the declared emergency.

At State discretion, it may temporarily provide continuous eligibility to CHIP enrollees who reside and/or work in a State or Federally declared disaster area for the duration of the declared emergency.

At State discretion, requirements related to timely processing of renewals and/or deadlines for families to respond to renewal requests may be temporarily waived for CHIP beneficiaries who reside and/or work in a State or Federally declared disaster area for the duration of the declared emergency.

At State discretion, the State may temporarily delay acting on changes in circumstances for CHIP beneficiaries other than the required changes in circumstances described in 42 CFR 457.342(a) cross-referencing 42 CFR 435.926(d),applicable to beneficiaries who reside and/or work in a State or Federally declared disaster area.

At State discretion, the requirement that a child is ineligible for CHIP for a period of three months from the date of the voluntary discontinuance of employer-sponsored group health insurance or individual insurance coverage may be temporarily waived for CHIP applicants who reside and/or work in a State or Federally declared disaster area for the duration of the declared emergency.

4.3.1 Describe the state's policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

Arizona does not currently have an enrollment cap or wait list in place. AHCCCS will submit a state plan amendment if the state decides to implement an enrollment cap or waiting list.

Effective Date: 10-01-17 Approval Date: 2-16-18

Elects to participate in the program, will receive the following KidsCare services, subject to the limitations described below: 6.1.4.1. X Coverage of all benefits that are provided to children that is the same as the benefits provided under the Medicaid State plan, including Early Periodic Screening, Diagnostic, and Treatment (EPSDT).

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver.

6.1.4.3.

Coverage that the State has extended to the entire Medicaid population.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage.

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state- based coverage applicable only in New York, Pennsylvania or Florida. (under 42 CFR 457.440)

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done).

6.1.4.7.

Other. (Describe)

6.2. The State elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.1.

Inpatient services (Section 2110(a)(1))

a. Inpatient hospital services, including medically necessary ancillary services, and emergency hospital services, if furnished by a licensed hospital and provided by or under the direction of a PCP or primary care practitioner according to federal and state law, rules, and AHCCCS Policies and Procedures. Inpatient hospital services include services provided in an institution specializing in the care and treatment of members with mental diseases. b. Services in an Institution for Mental Diseases (IMD) when the member requires services in an inpatient psychiatric hospital. IMD are available to members who are determined to require these services after enrollment in KidsCare. However, applicants in an IMD at the time of application are excluded from enrollment in KidsCare. c. Medically necessary transplant services, which are not experimental, if provided to correct or ameliorate disabilities, physical illnesses or conditions. Transplantation services will be authorized in accordance

Effective Date: 10-01-17 Approval Date: 2-16-18 with AHCCCS transplantation policies.

6.2.2.

Outpatient services (Section 2110(a)(2))

Outpatient hospital services ordinarily provided in hospitals, clinics, offices and other health care facilities by licensed health care providers. Outpatient hospital services include services provided by or under the direction of a PCP or primary care practitioner or licensed or certified behavioral health professional according to federal and state law. Certified behavioral health professionals include certified independent social workers, certified marriage/family therapists, and certified professional counselors.

6.2.3.

Physician services (Section 2110(a)(3))

Physician services if provided by or under the direction of a PCP, psychiatrist, or under the direction of a primary care practitioner according to federal and state law. Services are covered whether furnished in the office, the member’s home, a hospital, a nursing home or other setting.

Only psychiatrists, psychologists, certified psychiatric nurse practitioners, physician assistants, certified independent social workers, certified marriage/family therapists, and certified professional counselors may bill independently for behavioral health services. Other behavioral health professionals, behavioral health technicians and behavioral health paraprofessionals shall be affiliated with, an AHCCCS registered behavioral health agency and services shall be billed through that agency.

6.2.4.

Surgical services (Section 2110(a)(4))

Medically necessary surgical services under inpatient and outpatient services (Sections 6.2.1 and 6.2.2).

6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5))

a. Outpatient services (Section 6.2.2). b. Ambulatory services offered by a health center receiving funds under section 330 of the Public Health Services Act. c. Rural health clinic services and federally qualified health center services and other ambulatory services.

6.2.6.

Prescription drugs (Section 2110(a)(6))

a. Pharmaceutical services provided to a member if prescribed by the attending physician, practitioner, or dentist. b. Prescription drugs for covered transplantation services provided according to AHCCCS transplantation policies. c. Generally, medications dispensed by a physician or dentist are not covered.

6.2.7.

Over-the-counter medications (Section 2110(a)(7))

Effective Date: 10-01-17 Approval Date: 2-16-18 6.2.8.

Laboratory and radiological services (Section 2110(a)(8))

Laboratory, radiological and medical imaging services.

6.2.9.

Prenatal care and pre-pregnancy family services and supplies (Section 2110(a)(9))

a. The following family planning services: • Contraceptive counseling, medication, supplies and associated medical and laboratory exams • Natural family planning education or referral b. Infertility services and reversal of surgically induced infertility are not covered services. c. Family planning services do not include abortion or abortion counseling.

6.2.10.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12))

See Section 6.2.17--Dental services for coverage of dental devices. Vision services include prescriptive lenses.

6.2.11.

Disposable medical supplies (Section 2110(a)(13))

Medical supplies include consumable items that are disposable and are essential for the member’s health.

6.2.12.

Home and community-based health care services (Section 2110(a)(14))

6.2.13.

Nursing care services (Section 2110(a)(15))

a. Private duty nursing care, respiratory care services, and services provided by certified nurse practitioners in a home or other setting. b. Certified nurse midwife services when they are rendered in collaboration with a licensed physician or PCP or primary care practitioner in accordance with AHCCCS Policies and Procedures.

6.2.14.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16)

A physician shall provide written certification of necessity of abortion.

6.2.15.

Dental services (Section 2110(a)(17)) States updating their dental benefits must complete 6.2-DC (CHIPRA # 7, SHO # #09-012 issued October 7, 2009)

a. Dental services, including routine, preventive, therapeutic and emergency services.

b. Dentures and dental devices are covered if authorized in consultation with a dentist.

Effective Date: 10-01-17 Approval Date: 2-16-18 6.2.16.

Vision screenings and services (Section 2110(a)(24))

6.2.17.

Hearing screenings and services (Section 2110(a)(24))

6.2.18.

Case management services (Section 2110(a)(20))

Case management for persons with developmental disabilities.

6.2.19.

Care coordination services (Section 2110(a)(21))

Care coordination are available through contractors, primary care providers and behavioral health providers.

6.2.20.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

Therapy services are covered when necessary to prevent or ameliorate a condition, illness or injury, to prevent or correct abnormalities detected by screening or diagnostic procedures or to maintain a level of ability.

6.2.21.

Hospice care (Section 2110(a)(23))

Hospice services for a terminally ill member.

6.2.22.

EPSDT consistent with requirements of sections 1905(r) and 1902(a)(43) of the Act

6.2.22.1 The state assures that any limitations applied to the amount, duration, and scope of benefits described in Sections 6.2 and 6.3- BH of the CHIP state plan can be exceeded as medically necessary.

6.2.23.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (Section 2110(a)(24))

a. Services provided in a facility, home, or other setting if recognized by state law. b. Respiratory therapy. c. Eye examinations for prescriptive lenses. d. Immunizations, preventive health services, patient education, age and gender appropriate clinical screening test and periodic health exams.

6.2.24.

Premiums for private health care insurance coverage (Section 2110(a)(25))

6.2.25.

Medical transportation (Section 2110(a)(26))

Emergency ambulance and non-emergency transportation are covered services when the transportation is medically necessary.

6.2.26.

Enabling services (such as transportation, translation, and outreach services) (Section 2110(a)(27))

Effective Date: 10-01-17 Approval Date: 2-16-18

All printed materials are in English and Spanish. Outreach services will be available through AHCCCS, and others as specified in Section 4.4.5 and Section 5. 6.2.27.

Any other health care services or items specified by the Secretary and not included under this Section (Section 2110(a)(28)) 1. Nursing facility services in a nursing facility or in an alternative residential setting for a maximum of 90 days when the medical condition of the person indicates that these services are necessary to prevent hospitalization. 2. Total parenteral nutrition services. 3. Podiatry services and optometrist services if furnished by a licensed podiatrist or optometrist, respectively. 4. Other practitioner’s services are covered and include services provided by: a. Respiratory Therapists b. Certified Nurse Practitioners c. Certified Nurse Anesthetists d. Physician Assistants e. Nonphysician behavioral health professionals if the services are provided by social workers, physician assistants, psychologists, counselors, registered nurses, certified nurse practitioners, behavioral health technicians and other approved therapists who meet all applicable state standards. Except for behavioral health services provided by psychologists, psychiatric nurse practitioners, physician assistants, certified independent social workers, certified marriage/family therapists, and certified professional counselors, all nonphysician behavioral health professional services shall be provided by professionals affiliated with an approved behavioral health setting in accordance with rules and AHCCCS policies and procedures. 5. Home health services a. Home health services when necessary to prevent re-hospitalization or institutionalization, and may include home health nursing services, therapies, personal care, medical supplies, equipment and appliances and home health aide services. b. Nursing service and home health aide if provided on an intermittent or part time basis by a home health agency. When no home health agency exists, nursing services may be provided by a registered nurse. c. Therapy services.

Covered services are required to be authorized by the appropriate entity, unless otherwise indicated. Authorization by an appropriate entity shall be performed by at least one of the following: a PCP, primary care practitioner, or behavioral health professional as required by rule and AHCCCS policies and procedures. The appropriate entity shall authorize medically necessary services in compliance with applicable federal and state laws and regulations, AHCCCS policies and procedures and other applicable guidelines.

6.2-BH Behavioral Health Coverage Section 2103(c)(5) requires that states provide coverage to prevent, diagnose, and treat a broad range of mental health and substance use disorders in a culturally and linguistically appropriate manner for all CHIP enrollees, including pregnant women and unborn children.

Effective Date: 10-01-17 Approval Date: 2-16-18 6.2.1- BH Periodicity Schedule The state has adopted the following periodicity schedule for behavioral health screenings and assessments. Please specify any differences between any covered CHIP populations:

State-developed schedule American Academy of Pediatrics/ Bright Futures Other Nationally recognized periodicity schedule (please specify: ) Other: The AHCCCS EPSDT Periodicity Schedule is state developed to mirror the AAP/Bright Future EPSDT Periodicity Schedule. The one significant deviation alignment is that AHCCCS currently does not cover a thirty (30) month EPSDT Well Child Visit. To address this, the agency is undertaking an internal discussion and fiscal review to determine the feasibility of adding this visit to the schedule thus aligning with Bright Futures.

6.3- BH Covered Benefits Please check off the behavioral health services that are provided to the state’s CHIP populations, and provide a description of the amount, duration, and scope of each benefit. For each benefit, please also indicate whether the benefit is available for mental health and/or substance use disorders. If there are differences in benefits based on the population or type of condition being treated, please specify those differences.

If EPSDT is provided, as described at Section 6.2.26 and 6.2.26.1, the state should only check off the applicable benefits. It does not have to provide additional information regarding the amount, duration, and scope of each covered behavioral health benefit.

6.3.1- BH Behavioral health screenings and assessments. (Section 2103(c)(6)(A))

6.3.1.1- BH The state assures that all developmental and behavioral health recommendations outlined in the AAP Bright Futures periodicity schedule and United States Public Preventive Services Task Force (USPSTF) recommendations graded as A and B are covered as a part of the CHIP benefit package, as appropriate for the covered populations.

6.3.1.2- BH The state assures that it will implement a strategy to facilitate the use of age-appropriate validated behavioral health screening tools in primary care settings. Please describe how the state will facilitate the use of validated screening tools:

AHCCCS has policies and procedures that outline use of standardized, age- appropriate, and validated behavioral health screening tools in both primary care settings as well as behavioral health care settings. These requirements are also outlined in Contract with MCOs. The MCOs are tasked with educating providers on the screening tool requirements as well as care coordination and service referrals if member needs cannot fully be met by the attending provider. The MCOs have provider relations teams that make contact with providers on at least a quarterly basis as well as make themselves available any time providers have questions regarding service delivery. MCOs also send out mass notifications as warranted as well as utilize their websites and/or provider newsletters to provide timely updates on programmatic requirements.

6.3.2- BH Outpatient services (Sections 2110(a)(11) and 2110(a)(19))

Effective Date: 10-01-17 Approval Date: 2-16-18 a. Outpatient behavioral health services, other than substance abuse treatment services, including services furnished in a state operated mental hospital (e.g., IMD) and community-based services. b. Outpatient behavioral health services includes individual and/or group counseling/therapy, rehabilitation services, including basic and intensive partial care, emergency/crisis services, behavior management, psychosocial rehabilitation, evaluation and behavioral health related services. 6.3.2.1- BH Psychosocial treatment Provided for: Mental Health Substance Use Disorder

6.3.2.2- BH Tobacco cessation Provided for: Substance Use Disorder

6.3.2.3- BH Medication Assisted Treatment Provided for: Substance Use Disorder

6.3.2.3.1- BH Opioid Use Disorder

6.3.2.3.2- BH Alcohol Use Disorder

6.3.2.3.3- BH Other

6.3.2.4- BH Peer Support Provided for: Mental Health Substance Use Disorder

6.3.2.5- BH Caregiver Support Provided for: Mental Health Substance Use Disorder

6.3.2.6- BH Respite Care Provided for: Mental Health Substance Use Disorder

6.3.2.7- BH Intensive in-home services Provided for: Mental Health Substance Use Disorder

6.3.2.8- BH Intensive outpatient Provided for: Mental Health Substance Use Disorder

6.3.2.9- BH Psychosocial rehabilitation Provided for: Mental Health Substance Use Disorder

6.3.3- BH Day Treatment Provided for: Mental Health Substance Use Disorder

6.3.3.1- BH Partial Hospitalization Provided for: Mental Health Substance Use Disorder

6.3.4- BH

Inpatient services, including services furnished in a state-operated mental

Effective Date: 10-01-17 Approval Date: 2-16-18 hospital and including residential or other 24-hour therapeutically planned structural services (Sections 2110(a)(10) and 2110(a)(18))

a. Inpatient behavioral health services, other than inpatient and residential substance abuse treatment services, but including services furnished in a state operated mental hospital and including residential or other 24-hour therapeutically planned structured services. b. Services in a state operated mental hospital (e.g., Institution for Mental Diseases). IMD services are only available to members who are determined to require these services after enrollment. Applicants who are receiving IMD services at the time of application are excluded from enrollment in KidsCare. c. Partial care services are included as part of the inpatient benefit.

Provided for: Mental Health Substance Use Disorder

6.3.4.1- BH Residential Treatment Provided for: Mental Health Substance Use Disorder

6.3.4.2- BH Detoxification Provided for: Substance Use Disorder

6.3.5- BH Emergency services Provided for: Mental Health Substance Use Disorder

6.3.5.1- BH Crisis Intervention and Stabilization Provided for: Mental Health Substance Use Disorder

6.3.6- BH Continuing care services Provided for: Mental Health Substance Use Disorder

6.3.7- BH Care Coordination Provided for: Mental Health Substance Use Disorder

6.3.7.1- BH Intensive wraparound Provided for: Mental Health Substance Use Disorder

6.3.7.2- BH Care transition services Provided for: Mental Health Substance Use Disorder

6.3.8- BH Case Management Provided for: Mental Health Substance Use Disorder

6.3.9- BH Other Provided for: Mental Health Substance Use Disorder

6.4- BH Assessment Tools

6.4.1- BH Please specify or describe all of the tool(s) required by the state and/or each managed care entity:

Effective Date: 10-01-17 Approval Date: 2-16-18 ASAM Criteria (American Society Addiction Medicine) Mental Health Substance Use Disorders

InterQual Mental Health Substance Use Disorders

MCG Care Guidelines Mental Health Substance Use Disorders

CALOCUS/LOCUS (Child and Adolescent Level of Care Utilization System)

Mental Health Substance Use Disorders

CASII (Child and Adolescent Service Intensity Instrument) Mental Health Substance Use Disorders

CANS (Child and Adolescent Needs and Strengths) Mental Health Substance Use Disorders

State-specific criteria (e.g. state law or policies) (please describe) Mental Health Substance Use Disorders

Plan-specific criteria (please describe) Mental Health Substance Use Disorders

Other (please describe) Mental Health Substance Use Disorders

AHCCCS contract requires validated assessment tools be utilized for EPSDT aged members, as well as for adult members. AHCCCS required tool is limited to CALOCUS (formerly CASII). MCG criteria is for both SUD and MH.

No specific criteria or tools are required Mental Health Substance Use Disorders

6.4.2- BH Please describe the state’s strategy to facilitate the use of validated assessment tools for the treatment of behavioral health conditions.

The state requires the use of the CALOCUS for all child members aged 6 through 18. The ECSII, is currently required for the 0-5 population only through the Targeted Investments Program. This is not an exhaustive list, and may differ by provider agency and population served by each.

The state requires contractors to implement validated behavioral health screening tools by Primary Care Providers (PCPs) to determine if further assessment for behavioral health services is necessary. The state requires that providers serving EPSDT-aged members utilize AHCCCS approved EPSDT tracking forms and standardized developmental screening tools and that these providers are trained in the use of these tools.

For the children's population, Contractors are required to ensure provision of Trauma Informed Care (TIC) services, including routine trauma screenings and development of a network of TIC- certified therapists, as well as to promote service delivery for children age birth through five, including screening and high need identification as directed by AHCCCS through the use of

Effective Date: 10-01-17 Approval Date: 2-16-18 validated assessment tools. AHCCCS currently requires the use of the Child and Adolescent Level Of Care Utilization System (CALOCUS) (Formerly Child and Adolescent Service Intensity Instrument (CASII) tool for children 6-18 years of age, and requires the use of the Early Childhood Service Intensity Instrument (ECSII) through the Targeted Investments Program for the 0-5 population.

Contractors are required to promote expansion of services for children age birth through five through training and monitoring of specialists as directed by AHCCCS and in alignment with Evidence Based Practices for this population (i.e. Infant Toddler Mental Health Coalition of Arizona (ITMHCA) standards) and to utilize Substance Use Disorders (SUD) screening tools to identify youth with substance use disorders and refer to SUD specialty services as appropriate.

The American Society of Adiction Medicine (ASAM) Criteria is required for adults receiving behavioral health services, who have been identified as having a substance use disorder.

6.2.5- BH Covered Benefits The State assures the following related to the provision of behavioral health benefits in CHIP:

All behavioral health benefits are provided in a culturally and linguistically appropriate manner consistent with the requirements of section 2103(c)(6), regardless of delivery system.

The state will provide all behavioral health benefits consistent with 42 CFR 457.495 to ensure there are procedures in place to access covered services as well as appropriate and timely treatment and monitoring of children with chronic, complex or serious conditions

6.2- MHPAEA Section 2103(c)(6)(A) of the Social Security Act requires that, to the extent that it provides both medical/surgical benefits and mental health or substance use disorder benefits, a State child health plan ensures that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits comply with the mental health parity requirements of section 2705(a) of the Public Health Service Act in the same manner that such requirements apply to a group health plan. If the state child health plan provides for delivery of services through a managed care arrangement, this requirement applies to both the state and managed care plans. These requirements are also applicable to any additional benefits provided voluntarily to the child health plan population by managed care entities and will be considered as part of CMS’s contract review process at 42 CFR 457.1201(l).

6.2.1- MHPAEA Before completing a parity analysis, the State must determine whether each covered benefit is a medical/surgical, mental health, or substance use disorder benefit based on a standard that is consistent with state and federal law and generally recognized independent standards of medical practice. (42 CFR 457.496(f)(1)(i))

6.2.1.1- MHPAEA Please choose the standard(s) the state uses to determine whether a covered benefit is a medical/surgical benefit, mental health benefit, or substance use disorder benefit. The most current version of the standard elected must be used. If different standards are used for different benefit types, please specify the benefit type(s) to which each standard is applied. If “Other” is selected, please provide a description of that standard.

International Classification of Disease (ICD) Diagnostic and Statistical Manual of Mental Disorders (DSM) State guidelines (Describe: )

Effective Date: 10-01-17 Approval Date: 2-16-18 Other (Describe: ) 6.2.1.2- MHPAEA Does the State provide mental health and/or substance use disorder benefits?

Yes No

6.2.2- MHPAEA Section 2103(c)(6)(B) of the Social Security Act (the Act) provides that to the extent a State child health plan includes coverage of early and periodic screening, diagnostic, and treatment services (EPSDT) defined in section 1905(r) of the Act and provided in accordance with section 1902(a)(43) of the Act, the plan shall be deemed to satisfy the parity requirements of section 2103(c)(6)(A) of the Act.

6.2.2.1- MHPAEA Does the State child health plan provide coverage of EPSDT? The State must provide for coverage of EPSDT benefits, consistent with Medicaid statutory requirements, as indicated in section 6.2.26 of the State child health plan in order to answer “yes.”

Yes No

6.2.2.2- MHPAEA EPSDT benefits are provided to the following:

All children covered under the State child health plan. A subset of children covered under the State child health plan. Please describe the different populations (if applicable) covered under the State child health plan that are provided EPSDT benefits consistent with Medicaid statutory requirements.

6.2.2.3- MHPAEA To be deemed compliant with the MHPAEA parity requirements, States must provide EPSDT in accordance with sections 1902(a)(43) and 1905(r) of the Act (42 CFR 457.496(b)). The State assures each of the following for children eligible for EPSDT under the separate State child health plan:

All screening services, including screenings for mental health and substance use disorder conditions, are provided at intervals that align with a periodicity schedule that meets reasonable standards of medical or dental practice as well as when medically necessary to determine the existence of suspected illness or conditions. (Section 1905(r))

All diagnostic services described in 1905(a) of the Act are provided as needed to

Effective Date: 10-01-17 Approval Date: 2-16-18 diagnose suspected conditions or illnesses discovered through screening services, whether or not those services are covered under the Medicaid state plan. (Section 1905(r))

All items and services described in section 1905(a) of the Act are provided when needed to correct or ameliorate a defect or any physical or mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the Medicaid State plan. (Section 1905(r)(5))

Treatment limitations applied to services provided under the EPSDT benefit are not limited based on a monetary cap or budgetary constraints and may be exceeded as medically necessary to correct or ameliorate a medical or physical condition or illness. (Section 1905(r)(5))

Non-quantitative treatment limitations, such as definitions of medical necessity or criteria for medical necessity, are applied in an individualized manner that does not preclude coverage of any items or services necessary to correct or ameliorate any medical or physical condition or illness. (Section 1905(r)(5))

EPSDT benefits are not excluded on the basis of any condition, disorder, or diagnosis. (Section 1905(r)(5))

The provision of all requested EPSDT screening services, as well as any corrective treatments needed based on those screening services, are provided or arranged for as necessary. (Section 1902(a)(43))

All families with children eligible for the EPSDT benefit under the separate State child health plan are provided information and informed about the full range of services available to them. (Section 1902(a)(43)(A))

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1. X The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2. The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template).

Effective Date: 7-1-19

Approval Date:

Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

_____________________________________________________________________________ Table of Contents State/Territory Name: State Plan Amendment (SPA) #: This file contains the following documents in the order listed: 1) Approval Letter 2) State Plan Pages Arizona AZ-22-0007

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Children and Adults Health Programs Group

July 13, 2022

Jami Snyder Director Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034

Dear Ms. Snyder:

Your title XXI Children’s Health Insurance Program (CHIP) State Plan Amendment (SPA) number, AZ- 22-0007, submitted on June 1, 2022, has been approved. Through this SPA, Arizona has demonstrated compliance with the American Rescue Plan Act of 2021 (ARP). This SPA has an effective date of March 11, 2021 and extends through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period, as described in section 1135(g)(1)(B) of the Social Security Act (the Act).

Section 9821 of the ARP amended sections 2103(c)(11)(B) and 2103(e)(2) of the Act to mandate coverage of COVID-19 testing, treatment, and vaccines and their administration without cost-sharing or amount, duration, or scope limitations. Sections 2103(c)(11)(B) and 2103(e)(2) of the Act also require states to cover, without cost sharing, the treatment of conditions that may seriously complicate COVID- 19 treatment, during the period when a beneficiary is diagnosed with or is presumed to have COVID-19. The state provided the necessary assurances to demonstrate compliance with the ARP in accordance with the requirements of sections 2103(c)(11)(B) and 2103(e)(2) of the Act.

Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 457.65 that the state submit SPAs that are related to the COVID-19 public health emergency by the end of the state fiscal year in which they take effect. CMS is allowing states that submit SPAs after the last day of the state fiscal year to have an effective date in the prior state fiscal year, but no earlier than the effective date of the public health emergency. Arizona requested a waiver to obtain an earlier effective date of March 11, 2021. This letter approves Arizona’s request for a March 11, 2021 effective date.

Your Project Officer is Joyce Jordan. She is available to answer your questions concerning this amendment and other CHIP-related matters. Ms. Jordan’s contact information is as follows:

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop: S2-01-16

Baltimore, MD 21244-1850

Telephone: (410) 786-3413

E-mail: Joyce.Jordan@cms.hhs.gov

Page 2 – Ms. Jami Snyder

If you have additional questions, please contact Meg Barry, Director, Division of State Coverage Programs, at (410) 786-1536. We look forward to continuing to work with you and your staff.

Sincerely,

Amy Lutzky Deputy Director On Behalf of Anne Marie Costello, Deputy Director Center for Medicaid and CHIP Services

cc: Courtney Miller, Director, Medicaid and CHIP Operations Group

Jackie Glaze, Deputy Director, Medicaid and CHIP Operations Group /Signed by Amy Lutzky/





    
  

 





 



    





 

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Original Implementation Date: November 1, 1998

Amendment Effective Date: February 1, 2004 (premiums >150% FPL) July 1, 2004 (premiums 100%-150% FPL) May 1, 2009 (premiums >150% FPL) January 1, 2010 (enrollment cap) October 10, 2013 (remove wait list) July 26, 2016 (remove enrollment cap) August 6, 2016 (premium lock out period) October 1, 2017 (mental health parity) July 1, 2018 (Managed Care Regulations) July 1, 2019 (COVID-19 Disaster Response)

March 11, 2021 (ARP Coverage of COVID-19 Vaccines, Testing and Treatment)

Discontinuation of coverage of children aging out of CHIP during the COVID public health emergency became effective on June 26, 2020.

In the event of a disaster, the State will notify CMS of its intent to provide temporary adjustments to; flexibilities around delays in processing applications and renewals, the ability to waive the three month waiting period for applicants, the ability to waive existing premiums, and the ability to waive the premium lock-out period. In addition, the state is requesting to temporarily provide continuous eligibility to its CHIP population.

1.4-TC Tribal Consultation. Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred, and who was involved.

The State of Arizona seeks advice on a regular, ongoing basis from all of the federally-recognized tribes, Indian Health Service (IHS) Area Offices, tribal health programs operated under P.L. 93- 638, and urban Indian health programs in Arizona regarding Medicaid and CHIP matters. These matters include but are not limited to State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals, and proposals for demonstration projects. The AHCCCS Tribal Consultation Policy serves as a guidance document that includes the process by which reasonable notice and opportunity for consultation should occur and scenarios in which AHCCCS shall engage in the consultative process.

The frequency of consultation is dependent on the frequency in which policy changes are proposed. When a proposed policy change requires consultation, the State will to its best ability provide notice of the tribal consultation meeting date as well as a description of the proposed policy change to be discussed. Ideally, a consultation meeting, which provides an opportunity for discussion and verbal comments to be made regarding a proposed change, will occur either in-person or by conference call 45 days prior to the submission of the policy change to CMS. The State will also provide an opportunity for written comments. Ideally, during the 45-day period, tribes and I/T/U will be provided at least 30 days to submit written comments regarding the policy change for consideration. Verbal comments presented at the meeting as well as written comments will be included in an attachment to accompany the submission of a State Plan Amendment, waiver proposal, waiver renewal, or proposal for a demonstration project.

Effective Date: March 11, 2021

3

Approval Date: July 13, 2022


 





  
 
 
         

   

    

 

 

 





  
  
      



 

 
     
  
  
 

       




  
 




   
  
 
  
   
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